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Xu L, Yang R, Cao Y, Wang M, Yang X. Risk factors of diffuse alveolar hemorrhage in Chinese patients with systemic lupus erythematosus. Sci Rep 2023; 13:22381. [PMID: 38104153 PMCID: PMC10725482 DOI: 10.1038/s41598-023-49978-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 12/14/2023] [Indexed: 12/19/2023] Open
Abstract
This study aimed to investigate the frequency and features of diffuse alveolar hemorrhage (DAH) in Chinese patients with systemic lupus erythematosus (SLE) and evaluate the association of DAH with the features. A total of 943 patients with SLE were categorized into two groups: 896 patients without DAH and 47 patients with DAH. The demographic data, clinical and laboratory findings, and SLE disease activity index 2000 of all patients were statistically analyzed. The DAH frequency in patients with SLE was 4.98%, and the mortality rate of DAH was 42.55%. The clinical features with statistical differences between the two groups were analyzed by multivariate logistic regression, and the results suggested that shorter disease duration [odds ratio (OR): 0.972, 95% confidence interval (CI) 0.946, 0.998], younger age (OR: 0.867, 95% CI 0.764, 0.984), moderate (OR: 25.949, 95% CI 3.316, 203.065) or severe (OR: 24.904, 95% CI 2.675, 231.859) anemia, abnormally elevated levels of urine protein (OR: 10.839, 95% CI 1.351, 86.938) and serum creatinine (OR: 14.534, 95% CI 5.012, 42.142), interstitial lung disease (OR: 6.569, 95% CI 2.053, 21.021), and infection (OR: 8.890, 95% CI 3.580, 22.077) were independent risk factors for the occurrence of DAH in patients with SLE. Moderate or severe anemia was highly suggestive of DAH.
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Affiliation(s)
- Lishan Xu
- Department of Rheumatology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Rong Yang
- Follow-Up Center, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yingping Cao
- Department of Laboratory Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Meihua Wang
- Department of Laboratory Medicine, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Xuwei Yang
- Department of Rheumatology, Fujian Medical University Union Hospital, Fuzhou, China.
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Han JY, Cho SK, Sung YK. Epidemiology of systemic lupus erythematosus in Korea. JOURNAL OF RHEUMATIC DISEASES 2023; 30:211-219. [PMID: 37736591 PMCID: PMC10509641 DOI: 10.4078/jrd.2023.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/10/2023] [Accepted: 08/10/2023] [Indexed: 09/23/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by diverse organ system disabilities, predominantly affecting young females. The clinical manifestations of SLE encompass various organs, including the kidney, cardiovascular system, and central nervous system. Young females with SLE experience higher mortality rates than the general population, making it imperative to gain insights into the disease patterns and associated factors. The current review examines the epidemiological studies to analyze the prevalence, incidence, and mortality trends of SLE in Korea and compares them with the findings from other countries. We aim to identify potential similarities, differences, and factors contributing to the burden of SLE in different populations by exploring the comparative epidemiological aspects. The knowledge derived from this comparison would aid in advancing the overall management of SLE in Korea.
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Affiliation(s)
- Jung-Yong Han
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Korea
| | - Soo-Kyung Cho
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Korea
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Li M, Bai W, Wang Y, Song L, Zhang S, Zhao J, Wu C, Li M, Tian X, Zeng X. Infection in systemic lupus erythematosus-associated diffuse alveolar hemorrhage: a potential key to improve outcomes. Clin Rheumatol 2023; 42:1573-1584. [PMID: 36797549 DOI: 10.1007/s10067-023-06517-8] [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: 08/29/2022] [Revised: 12/21/2022] [Accepted: 01/17/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVES This study aimed to investigate the clinical characteristics, outcomes, and associated factors of patients with systemic lupus erythematosus-associated diffusive alveolar hemorrhage (SLE-DAH) stratified by infection status in a national representative cohort. METHODS This single-center retrospective study included 124 consecutive patients with SLE-DAH in a tertiary care center between 2006 and 2021. The diagnosis of DAH was made based on a comprehensive evaluation of clinical manifestations, laboratory and radiologic findings, and bronchoalveolar lavage. Demographics, clinical features, and survival curves were compared between patients with bacterial, non-bacterial, and non-infection groups. Univariate and multivariate logistic regression analyses were performed to determine the factors independently associated with bacterial infection in SLE-DAH. RESULTS Fifty-eight patients with SLE-DAH developed bacterial infection after DAH occurrence, thirty-two patients developed fungal and/or viral infection, and thirty-four patients were categorized as non-infection. The bacterial infection group have a worse prognosis (OR 3.059, 95%CI 1.469-6.369, p = 0.002) compared with the other two groups, with a mortality rate of 60.3% within 180 days after DAH occurrence. Factors independently associated with bacterial infections in SLE-DAH included hematuria (OR 4.523, 95%CI 1.068-19.155, p = 0.040), hemoglobin drop in the first 24 h after DAH occurred (OR 1.056, 95%CI 1.001-1.115, p = 0.049), and anti-Smith antibody (OR 0.167, 95%CI 0.052-0.535, p = 0.003). Glucocorticoid pulse therapy and cyclophosphamide were administered in more than 50% of patients regardless of their infectious status. According to clinical experience at our hospital and in previous studies, we recommended a comprehensive management algorithm for SLE-DAH based on infection stratification. CONCLUSION Infection, especially bacterial infection, is a severe complication and prognostic factor of SLE-DAH. Comprehensive management strategies, including diagnosis, evaluation, treatment, and monitoring, based on infection stratification may fundamentally improve outcomes of patients with SLE-DAH. Key Points • Bacterial infection is an important, but neglected, prognosis factor of systemic lupus erythematosus (SLE)-associated diffusive alveolar hemorrhage (DAH). • Hematuria, hemoglobin drop, and anti-Smith antibody can independently predict bacterial infections in SLE-DAH. • We put forward a comprehensive management algorithm based on infection stratification for SLE-DAH.
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Affiliation(s)
- Mucong Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Wei Bai
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Yanhong Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking, Union Medical College, Beijing, 100730, China
| | - Lan Song
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Shangzhu Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Chanyuan Wu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
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Zhuang H, Hudson E, Han S, Arja RD, Hui W, Lu L, Reeves WH. Microvascular lung injury and endoplasmic reticulum stress in systemic lupus erythematosus-associated alveolar hemorrhage and pulmonary vasculitis. Am J Physiol Lung Cell Mol Physiol 2022; 323:L715-L729. [PMID: 36255715 PMCID: PMC9744657 DOI: 10.1152/ajplung.00051.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 10/13/2022] [Accepted: 10/13/2022] [Indexed: 12/14/2022] Open
Abstract
Human COPA mutations affecting retrograde Golgi-to-endoplasmic reticulum (ER) protein transport cause diffuse alveolar hemorrhage (DAH) and ER stress ("COPA syndrome"). Patients with SLE also can develop DAH. C57BL/6 (B6) mice with pristane-induced lupus develop monocyte-dependent DAH indistinguishable from human DAH, whereas BALB/c mice are resistant. We examined Copa and ER stress in pristane-induced lupus. Copa expression, ER stress, vascular injury, and apoptosis were assessed in mice and COPA was quantified in blood from patients with SLE. Copa mRNA and protein expression were impaired in B6 mice with pristane-induced DAH, but not in pristane-treated BALB/c mice. An ER stress response (increased Hsp5a/BiP, Ddit3/CHOP, Eif2a, and spliced Xbp1) was seen in lungs from pristane-treated B6, but not BALB/c, mice. Resistance of BALB/c mice to DAH was overcome by treating them with low-dose thapsigargin plus pristane. CB6F1 mice did not develop DAH or ER stress, suggesting that susceptibility was recessive. Increased pulmonary expression of von Willebrand factor (Vwf), a marker of endothelial injury, and the chemokine Ccl2 in DAH suggested that pristane promotes lung microvascular injury and monocyte recruitment. Consistent with that possibility, lung endothelial cells and infiltrating bone marrow-derived cells from pristane-treated B6 mice expressed BiP and showed evidence of apoptosis (annexin-V and activated caspase-3 staining). COPA expression also was low in patients with SLE with lung involvement. Pristane-induced DAH may be initiated by endothelial injury, resulting in ER stress, apoptosis of lung endothelial cells, and recruitment of myeloid cells that propagate lung injury. The pathogenesis of DAH in SLE and COPA syndrome may overlap.
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Affiliation(s)
- Haoyang Zhuang
- Division of Rheumatology, Allergy, & Clinical Immunology, University of Florida, Gainesville, Florida
| | - Erin Hudson
- Division of Rheumatology, Allergy, & Clinical Immunology, University of Florida, Gainesville, Florida
| | - Shuhong Han
- Division of Rheumatology, Allergy, & Clinical Immunology, University of Florida, Gainesville, Florida
| | - Rawad Daniel Arja
- Division of Rheumatology, Allergy, & Clinical Immunology, University of Florida, Gainesville, Florida
| | - Winnie Hui
- Division of Rheumatology, Allergy, & Clinical Immunology, University of Florida, Gainesville, Florida
| | - Li Lu
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Westley H Reeves
- Division of Rheumatology, Allergy, & Clinical Immunology, University of Florida, Gainesville, Florida
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, Florida
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Shin JI, Lee KH, Park S, Yang JW, Kim HJ, Song K, Lee S, Na H, Jang YJ, Nam JY, Kim S, Lee C, Hong C, Kim C, Kim M, Choi U, Seo J, Jin H, Yi B, Jeong SJ, Sheok YO, Kim H, Lee S, Lee S, Jeong YS, Park SJ, Kim JH, Kronbichler A. Systemic Lupus Erythematosus and Lung Involvement: A Comprehensive Review. J Clin Med 2022; 11:jcm11226714. [PMID: 36431192 PMCID: PMC9698564 DOI: 10.3390/jcm11226714] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/27/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a complex autoimmune disease with multiorgan manifestations, including pleuropulmonary involvement (20-90%). The precise mechanism of pleuropulmonary involvement in SLE is not well-understood; however, systemic type 1 interferons, circulating immune complexes, and neutrophils seem to play essential roles. There are eight types of pleuropulmonary involvement: lupus pleuritis, pleural effusion, acute lupus pneumonitis, shrinking lung syndrome, interstitial lung disease, diffuse alveolar hemorrhage (DAH), pulmonary arterial hypertension, and pulmonary embolism. DAH has a high mortality rate (68-75%). The diagnostic tools for pleuropulmonary involvement in SLE include chest X-ray (CXR), computed tomography (CT), pulmonary function tests (PFT), bronchoalveolar lavage, biopsy, technetium-99m hexamethylprophylene amine oxime perfusion scan, and (18)F-fluorodeoxyglucose positron emission tomography. An approach for detecting pleuropulmonary involvement in SLE includes high-resolution CT, CXR, and PFT. Little is known about specific therapies for pleuropulmonary involvement in SLE. However, immunosuppressive therapies such as corticosteroids and cyclophosphamide are generally used. Rituximab has also been successfully used in three of the eight pleuropulmonary involvement forms: lupus pleuritis, acute lupus pneumonitis, and shrinking lung syndrome. Pleuropulmonary manifestations are part of the clinical criteria for SLE diagnosis. However, no review article has focused on the involvement of pleuropulmonary disease in SLE. Therefore, this article summarizes the literature on the epidemiology, pathogenesis, diagnosis, and management of pleuropulmonary involvement in SLE.
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Affiliation(s)
- Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Seoyeon Park
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Hyung Ju Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Kwanhyuk Song
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Seungyeon Lee
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hyeyoung Na
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Yong Jun Jang
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Ju Yun Nam
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Soojin Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Chaehyun Lee
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Chanhee Hong
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Chohwan Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Minhyuk Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Uichang Choi
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jaeho Seo
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hyunsoo Jin
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - BoMi Yi
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Se Jin Jeong
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Yeon Ook Sheok
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Haedong Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Sangmin Lee
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Sangwon Lee
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Young Soo Jeong
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Se Jin Park
- Department of Pediatrics, Eulji University School of Medicine, Daejeon 34824, Republic of Korea
| | - Ji Hong Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 26426, Republic of Korea
- Correspondence:
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Schattner A. Unusual Presentations of Systemic Lupus Erythematosus: A Narrative Review. Am J Med 2022; 135:1178-1187. [PMID: 35671786 DOI: 10.1016/j.amjmed.2022.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 05/01/2022] [Accepted: 05/16/2022] [Indexed: 11/01/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease characterized by an almost 10:1 female predominance, the presence of deleterious nuclear autoantibodies, a tendency for flare, and striking protean manifestations. Early diagnosis is associated with less damage accrual, lower costs, and improved quality of life due to timely treatment. However, early disease may not uncommonly show nonspecific presentation, a single classification criterion, or an unusual organ involvement contributing to frequent, often substantial diagnostic delays. We reviewed the literature (1982-2022) to accumulate and classify all reports of rare, atypical, and unusual presentations. These can involve almost every organ and system, and thus, present to physicians in every discipline and setting. Increasing physicians' awareness of the potential of occult SLE to appear in varied, diverse, and unexpected presentations, may encourage the inclusion of SLE in the differential. Informed history and examination focusing on systemic and joint symptoms and mucocutaneous involvement, and basic tests (focusing on leukopenia, thrombocytopenia, and proteinuria; followed by antinuclear antibodies and complement levels) will correctly diagnose most patients on presentation or within the following months and enable timely treatment.
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Affiliation(s)
- Ami Schattner
- The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel.
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Aurangabadkar GM, Aurangabadkar MY, Choudhary SS, Ali SN, Khan SM, Jadhav US. Pulmonary Manifestations in Rheumatological Diseases. Cureus 2022; 14:e29628. [PMID: 36321051 PMCID: PMC9612897 DOI: 10.7759/cureus.29628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022] Open
Abstract
Pulmonary involvement complicates the various aspects of care in patients suffering from autoimmune disorders. The epidemiological data generated over the last 10 to 15 years have improved the overall understanding of the risk factors and pathophysiological mechanisms involved in pulmonary involvement in rheumatological conditions. Recent advances in genetics have provided superior insight into the pathogenesis of autoimmune diseases and the underlying pulmonary involvement. This review article provides a concise overview of the four most common rheumatological conditions associated with pulmonary involvement: systemic lupus erythematosus (SLE), dermatomyositis/polymyositis, rheumatoid arthritis (RA), and systemic sclerosis (SSc). The clinical, epidemiological, and genetic aspects of these diseases are summarized in this article with particular emphasis on the characteristic patterns of pulmonary involvement in radiological imaging and various treatment options for each of these autoimmune diseases and their lung manifestations.
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Saha BK, Chong WH, Milman NT. Differentiation of idiopathic pulmonary hemosiderosis from rheumatologic and autoimmune diseases causing diffuse alveolar hemorrhage: establishing a diagnostic approach. Clin Rheumatol 2022; 41:325-336. [PMID: 34491458 DOI: 10.1007/s10067-021-05895-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 12/11/2022]
Abstract
This narrative review provides an overview of diffuse alveolar hemorrhage (DAH) associated with rheumatologic and autoimmune diseases and their differentiation from idiopathic pulmonary hemosiderosis (IPH). Relevant immunologic diseases associated with DAH are discussed, and a diagnostic flowchart is proposed to establish a "definitive" diagnosis of IPH within the spectrum of DAH. IPH is a rare cause of recurrent DAH both in children and adults. In adults, a definitive diagnosis of IPH requires a lung biopsy and histopathologic examination demonstrating intraalveolar hemorrhage, hemosiderin-laden macrophages, and a variable degree of fibrosis in the absence of both capillaritis and cellular inflammation. The presence of small vessel vasculitis points towards immunologic, well-differentiated, or sometimes undifferentiated rheumatologic diseases. However, it is essential to recognize that many rheumatologic diseases may in the initial phase present with DAH without any evidence of capillaritis, thus mimicking IPH. Although not definitely established, it is likely that immunologic processes are involved in IPH, and we, therefore, suggest the consideration of a more suitable term for the disease, e.g., "Immune-mediated Pulmonary Hemosiderosis" to acknowledge the aberrancy in the immune parameters and a positive response to immunosuppressive therapy.
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Affiliation(s)
- Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, MO, USA.
| | - Woon H Chong
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY, USA
| | - Nils T Milman
- Department of Clinical Biochemistry, Næstved Hospital, University College Zealand, 4700, Næstved, Denmark
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Rajasekhar L, Devarasetti P, Appani S, Prasad Irlapati R. Predictors of mortality in diffuse alveolar hemorrhage in systemic lupus erythematosus. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_82_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sangli SS, Ryu JH, Baqir M. Diffuse Alveolar Hemorrhage in Primary Versus Secondary Antiphospholipid Syndrome. J Clin Rheumatol 2021; 27:e297-e301. [PMID: 32195850 DOI: 10.1097/rhu.0000000000001358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) occurs in patients with both primary and secondary antiphospholipid antibody syndrome (APS). We sought to determine the differences in clinical presentation, management, and outcomes of DAH in these patients. METHODS We performed a medical records review study and reviewed 30 patients with DAH in the setting of primary and secondary antiphospholipid syndrome seen at our institution between January 1, 1997, and December 31, 2018. We analyzed their demographics, clinical presentation, laboratory values, imaging studies, lung pathology results, management, and outcomes. RESULTS The patients in the secondary APS cohort were younger (median age, 48.5 vs 58 years) and comprised more females (75% vs 17%) compared with those with primary APS (p < 0.05). Two thirds of patients in the secondary APS group were anemic compared with less than one fourth in the primary APS group (p = 0.005). At the time of the first episode of DAH, the patients in the secondary APS required invasive and noninvasive ventilation, antibiotics, and combination immunosuppressive therapy (includes a combination of glucocorticoids with immunosuppressants or intravenous immunoglobulins or plasma exchange) more often compared with those with primary APS. There was only one in-hospital death (3% in-hospital mortality). One-year and 5-year mortality rates were 20% and 27%, respectively, with no significant difference between the primary and secondary APS groups. CONCLUSIONS Diffuse alveolar hemorrhage in the setting of APS, especially secondary APS, can be severe. However, in-hospital mortality is uncommon with current management strategies.
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Affiliation(s)
- Swathi S Sangli
- From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Xu T, Zhang G, Lin H, Xie Y, Feng Y, Zhang X, Dong G. Clinical Characteristics and Risk Factors of Diffuse Alveolar Hemorrhage in Systemic Lupus Erythematosus: a Systematic Review and Meta-Analysis Based on Observational Studies. Clin Rev Allergy Immunol 2021; 59:295-303. [PMID: 31440948 DOI: 10.1007/s12016-019-08763-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare but potentially deadly manifestation of systemic lupus erythematosus (SLE). The aim of this study was to investigate the clinical characteristics and risk factors of DAH in SLE. A systematic review and meta-analysis of previous observational studies compared the clinical characteristics and risk factors between DAH-SLE and SLE patients without DAH. A total of 5 observational studies were included in this meta-analysis. Compared with the SLE patients without DAH, DAH-SLE patients had a significantly higher incidence of neuropsychiatric events (OR = 4.321, 95% CI (1.686-11.073), P = 0.002, I2 = 49.2%), nephritis (OR = 3.146, 95% CI (1.663-5.955,), P = 0.000, I2 = 0.0%), serositis (OR = 6.028, 95% CI (1.418-25.635), P = 0.015, I2 = 80.3%), dyspnea (OR = 31.241,95% CI (0.202-4833.203), P = 0.181, I2 = 94.6%), and a significantly lower level of C3 (SMD = - 1.358, 95% CI - 1.685, - 1.031), P = 0.000, I2 = 98.0%), C4 (SMD = - 1.251, 95% CI (- 1.648, - 0.855), P = 0.000, I2 = 87.7%), hemoglobin (SMD = - 2.074, 95% CI (- 2.433, - 1.715), P = 0.000, I2 = 94.2%), and a higher SLEDAI-2K score (SMD = 1.284, 95% CI (0.959, 1.608), P = 0.000, I2 = 98.2%). However, due to significant heterogeneity, some of these results should be interpreted cautiously. Nevertheless, when the above abnormal indicators are found, especially neuropsychiatric involvement and nephritis, besides the existed diagnostic criteria for DAH in SLE patients, a diagnosis for DAH should be considered and relevant treatment timely initiated. Further prospective multi-center SLE studies with a large cohort of patients and long-term follow-up are needed to clarify further or find out the specific clinical indexes for DAH in SLE patients.
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Affiliation(s)
- Ting Xu
- Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan Second Road, Guangzhou, 510080, Guangdong, China
| | - Guangfeng Zhang
- Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan Second Road, Guangzhou, 510080, Guangdong, China
| | - Haobo Lin
- Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan Second Road, Guangzhou, 510080, Guangdong, China
| | - Yuesheng Xie
- Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan Second Road, Guangzhou, 510080, Guangdong, China
| | - Yuan Feng
- Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan Second Road, Guangzhou, 510080, Guangdong, China
| | - Xiao Zhang
- Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan Second Road, Guangzhou, 510080, Guangdong, China.
| | - Guangfu Dong
- Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan Second Road, Guangzhou, 510080, Guangdong, China.
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12
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Zhuang H, Han S, Lu L, Reeves WH. Myxomavirus serpin alters macrophage function and prevents diffuse alveolar hemorrhage in pristane-induced lupus. Clin Immunol 2021; 229:108764. [PMID: 34089860 PMCID: PMC10619960 DOI: 10.1016/j.clim.2021.108764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 04/19/2021] [Accepted: 05/31/2021] [Indexed: 01/19/2023]
Abstract
C57BL/6 mice with pristane-induced lupus develop macrophage-dependent diffuse alveolar hemorrhage (DAH), which is blocked by treatment with liver X receptor (LXR) agonists and is exacerbated by low IL-10 levels. Serp-1, a myxomavirus-encoded serpin that impairs macrophage activation and plasminogen activation, blocks DAH caused by MHV68 infection. We investigated whether Serp-1 also could block DAH in pristane-induced lupus. Pristane-induced DAH was prevented by treatment with recombinant Serp-1 and macrophages from Serp1-treated mice exhibited an anti-inflammatory M2-like phenotype. Therapy activated LXR, promoting M2 polarization and expression of Kruppel-like factor-4 (KLH4), which upregulates IL-10. In contrast, deficiency of tissue plasminogen activator or plasminogen activator inhibitor had little effect on DAH. We conclude that Serp-1 blocks pristane-induced lung hemorrhage by enhancing LXR-regulated M2 macrophage polarization and KLH4-regulated IL-10 production. In view of the similarities between DAH in pristane-treated mice and SLE patients, Serp-1 may represent a potential new therapy for this severe complication of SLE.
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Affiliation(s)
- Haoyang Zhuang
- Division of Rheumatology & Clinical Immunology, University of Florida, Gainesville, FL 32610, United States of America.
| | - Shuhong Han
- Division of Rheumatology & Clinical Immunology, University of Florida, Gainesville, FL 32610, United States of America
| | - Li Lu
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, FL 32610, United States of America
| | - Westley H Reeves
- Division of Rheumatology & Clinical Immunology, University of Florida, Gainesville, FL 32610, United States of America
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13
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Chen YC, Chou YC, Hsieh YT, Kuo PY, Yang ML, Chong HE, Wu CL, Shiau AL, Wang CR. Targeting Intra-Pulmonary P53-Dependent Long Non-Coding RNA Expression as a Therapeutic Intervention for Systemic Lupus Erythematosus-Associated Diffuse Alveolar Hemorrhage. Int J Mol Sci 2021; 22:ijms22136948. [PMID: 34203338 PMCID: PMC8268786 DOI: 10.3390/ijms22136948] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/17/2021] [Accepted: 06/23/2021] [Indexed: 12/13/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) in systemic lupus erythematosus (SLE) is associated with significant mortality, requiring a thorough understanding of its complex mechanisms to develop novel therapeutics for disease control. Activated p53-dependent apoptosis with dysregulated long non-coding RNA (lncRNA) expression is involved in the SLE pathogenesis and correlated with clinical activity. We examined the expression of apoptosis-related p53-dependent lncRNA, including H19, HOTAIR and lincRNA-p21 in SLE-associated DAH patients. Increased lincRNA-p21 levels were detected in circulating mononuclear cells, mainly in CD4+ and CD14+ cells. Higher expression of p53, lincRNA-p21 and cell apoptosis was identified in lung tissues. Lentivirus-based short hairpin RNA (shRNA)-transduced stable transfectants were created for examining the targeting efficacy in lncRNA. Under pristane stimulation, alveolar epithelial cells had increased p53, lincRNA-p21 and downstream Bax levels with elevated apoptotic ratios. After pristane injection, C57/BL6 mice developed DAH with increased pulmonary expression of p53, lincRNA-p21 and cell apoptosis. Intra-pulmonary delivery of shRNA targeting lincRNA-p21 reduced hemorrhage frequencies and improved anemia status through decreasing Bax expression and cell apoptosis. Our findings demonstrate increased p53-dependent lncRNA expression with accelerated cell apoptosis in the lungs of SLE-associated DAH patients, and show the therapeutic potential of targeting intra-pulmonary lncRNA expression in a pristane-induced model of DAH.
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Affiliation(s)
- Yi-Cheng Chen
- Department of Internal Medicine, Medical College and Hospital, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-C.C.); (H.-E.C.)
- Department of Medical Research, Ditmanson Medical Foundation, Chiayi Christian Hospital, Chiayi 600566, Taiwan
- Department of Biochemistry and Molecular Biology, National Cheng Kung University Medical College, Tainan 70403, Taiwan;
| | - Yu-Chi Chou
- Biomedical Translation Research Center, Academia Sinica, Taipei 11529, Taiwan;
| | - Yu-Tung Hsieh
- Department of Microbiology and Immunology, Medical College, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-T.H.); (P.-Y.K.); (M.-L.Y.); (A.-L.S.)
| | - Pin-Yu Kuo
- Department of Microbiology and Immunology, Medical College, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-T.H.); (P.-Y.K.); (M.-L.Y.); (A.-L.S.)
| | - Mei-Lin Yang
- Department of Microbiology and Immunology, Medical College, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-T.H.); (P.-Y.K.); (M.-L.Y.); (A.-L.S.)
| | - Hao-Earn Chong
- Department of Internal Medicine, Medical College and Hospital, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-C.C.); (H.-E.C.)
| | - Chao-Liang Wu
- Department of Biochemistry and Molecular Biology, National Cheng Kung University Medical College, Tainan 70403, Taiwan;
| | - Ai-Li Shiau
- Department of Microbiology and Immunology, Medical College, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-T.H.); (P.-Y.K.); (M.-L.Y.); (A.-L.S.)
| | - Chrong-Reen Wang
- Department of Internal Medicine, Medical College and Hospital, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-C.C.); (H.-E.C.)
- Department of Microbiology and Immunology, Medical College, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-T.H.); (P.-Y.K.); (M.-L.Y.); (A.-L.S.)
- Correspondence: ; Tel.: +886-6-235-3535 (ext. 5366)
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14
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Diffuse Alveolar Hemorrhage: A Cohort of Patients With Systemic Lupus Erythematosus. J Clin Rheumatol 2021; 26:S153-S157. [PMID: 31895107 DOI: 10.1097/rhu.0000000000001228] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Diffuse alveolar hemorrhage (DAH) is an uncommon but potentially fatal complication in patients with systemic lupus erythematosus (SLE). Its prognosis and factors associated with mortality are not completely clear, although invasive mechanical ventilation (IMV), use of cyclophosphamide, a high Acute Physiology and Chronic Health Evaluation II score, and infections are associated with high mortality rates. We investigated clinical and immunologic characteristics and factors associated with mortality in a cohort of Latin American patients with SLE who developed DAH. METHODS A medical records review study was conducted of patients with SLE who were admitted to the intensive care unit (ICU) with DAH between 2011 and 2018. Clinical, laboratory, and treatment variables were compared between survivors and nonsurvivors. RESULTS A total of 17 patients with SLE presented with DAH during the study period, of whom 11 (64.70%) were women. The median age was 28 (19-38.5) years. The Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) on admission to the ICU was 15.94 ± 10.07. All patients received pulse methylprednisolone and therapeutic plasma exchange, and 13 (76. %) also received cyclophosphamide. During the hospital stay, 5 patients (29.41%) died. A high SLEDAI on admission, low albumin, and days of IMV and inotropic/vasoactive support were statistically significant in comparing nonsurvivors with survivors. Other scales of disease severity commonly used in the ICU, however, were not significantly associated with a fatal outcome. CONCLUSIONS Hypoalbuminemia, longer duration of IMV or inotropic/vasoactive treatment, and a high SLEDAI are potential prognostic factors for mortality in patients with SLE and DAH admitted to the ICU.
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15
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Jee AS, Sheehy R, Hopkins P, Corte TJ, Grainge C, Troy LK, Symons K, Spencer LM, Reynolds PN, Chapman S, de Boer S, Reddy T, Holland AE, Chambers DC, Glaspole IN, Jo HE, Bleasel JF, Wrobel JP, Dowman L, Parker MJS, Wilsher ML, Goh NSL, Moodley Y, Keir GJ. Diagnosis and management of connective tissue disease-associated interstitial lung disease in Australia and New Zealand: A position statement from the Thoracic Society of Australia and New Zealand. Respirology 2020; 26:23-51. [PMID: 33233015 PMCID: PMC7894187 DOI: 10.1111/resp.13977] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/26/2020] [Accepted: 10/22/2020] [Indexed: 12/12/2022]
Abstract
Pulmonary complications in CTD are common and can involve the interstitium, airways, pleura and pulmonary vasculature. ILD can occur in all CTD (CTD-ILD), and may vary from limited, non-progressive lung involvement, to fulminant, life-threatening disease. Given the potential for major adverse outcomes in CTD-ILD, accurate diagnosis, assessment and careful consideration of therapeutic intervention are a priority. Limited data are available to guide management decisions in CTD-ILD. Autoimmune-mediated pulmonary inflammation is considered a key pathobiological pathway in these disorders, and immunosuppressive therapy is generally regarded the cornerstone of treatment for severe and/or progressive CTD-ILD. However, the natural history of CTD-ILD in individual patients can be difficult to predict, and deciding who to treat, when and with what agent can be challenging. Establishing realistic therapeutic goals from both the patient and clinician perspective requires considerable expertise. The document aims to provide a framework for clinicians to aid in the assessment and management of ILD in the major CTD. A suggested approach to diagnosis and monitoring of CTD-ILD and, where available, evidence-based, disease-specific approaches to treatment have been provided.
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Affiliation(s)
- Adelle S Jee
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia
| | - Robert Sheehy
- Department of Respiratory Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Peter Hopkins
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Queensland Lung Transplant service, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Tamera J Corte
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia
| | - Christopher Grainge
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Respiratory Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Lauren K Troy
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Karen Symons
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Lissa M Spencer
- Department of Physiotherapy, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Paul N Reynolds
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia.,Lung Research Laboratory, University of Adelaide, Adelaide, SA, Australia
| | - Sally Chapman
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sally de Boer
- Respiratory Services, Auckland District Health Board, Auckland, New Zealand
| | - Taryn Reddy
- Department of Medical Imaging, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Anne E Holland
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, VIC, Australia.,Department of Physiotherapy, Alfred Health, Melbourne, VIC, Australia.,Institute for Breathing and Sleep, Melbourne, VIC, Australia
| | - Daniel C Chambers
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Queensland Lung Transplant service, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Ian N Glaspole
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Respiratory Medicine, Alfred Hospital, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Helen E Jo
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia
| | - Jane F Bleasel
- Central Clinical School, University of Sydney, Sydney, NSW, Australia.,Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jeremy P Wrobel
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, WA, Australia.,Department of Medicine, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Leona Dowman
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, VIC, Australia.,Physiotherapy Department, Austin Health, Melbourne, VIC, Australia
| | - Matthew J S Parker
- Central Clinical School, University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Margaret L Wilsher
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,Respiratory Services, Auckland District Health Board, Auckland, New Zealand.,Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Nicole S L Goh
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, VIC, Australia.,Institute for Breathing and Sleep, Melbourne, VIC, Australia.,Department of Respiratory Medicine, Austin Hospital, Melbourne, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Yuben Moodley
- NHMRC Centre of Research Excellence in Pulmonary Fibrosis, Sydney, NSW, Australia.,University of Western Australia, Institute for Respiratory Health, Perth, WA, Australia.,Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Gregory J Keir
- Department of Respiratory Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
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16
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In-hospital mortality in patients with systemic lupus erythematosus: a study from Jordan 2002–2017. Rheumatol Int 2020; 40:711-717. [DOI: 10.1007/s00296-020-04538-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/19/2020] [Indexed: 10/24/2022]
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17
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Rajvanshi N, Chacham S, Chegondi M, Goyal JP, Singh S. Pulmonary Hemosiderosis in a Child With Systemic Lupus Erythematosus: A Rare Presentation. Cureus 2020; 12:e7890. [PMID: 32489744 PMCID: PMC7255548 DOI: 10.7759/cureus.7890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Pulmonary hemorrhage is an uncommon manifestation in children and is often associated with systemic lupus erythematosus. We report a case of an adolescent girl who presented to our hospital with recurrent episodes of fever, cough, and breathlessness. Later on, she was diagnosed with pulmonary hemosiderosis as a manifestation of systemic lupus erythematosus. She was started on immunosuppressive therapy initially with prednisolone and subsequently with azathioprine and hydroxychloroquine, which improved the clinical status of the child.
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Affiliation(s)
- Nikhil Rajvanshi
- Pediatrics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Swathi Chacham
- Pediatrics, All India Institute of Medical Sciences, Rishikesh, IND
| | | | - Jagdish P Goyal
- Pediatrics, All India Institute of Medical Sciences, Jodhpur, IND
| | - Surjit Singh
- Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
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18
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Yousif PA, Moshrefi H, Meysami A, Alkhatib AH. Lupus-Induced Vasculitis and Multiple Organ Dysfunction Syndrome as the First Presentation of Systemic Lupus Erythematosus (SLE) in Pregnancy. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e921299. [PMID: 32284523 PMCID: PMC7176590 DOI: 10.12659/ajcr.921299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Patient: Female, 21-year-old Final Diagnosis: Diffuse alveolar hemorrhage Symptoms: Cough • dyspnea • fever • rash • sore throat Medication: — Clinical Procedure: — Specialty: Rheumatology
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Affiliation(s)
- Patrick A Yousif
- Department of Internal Medicine, Detroit Medical Center Sinai-Grace Hospital/Wayne State University, Detroit, MI, USA
| | - Hameadreza Moshrefi
- Department of Rheumatology, Henry Ford Hospital/Wayne State University, Detroit, MI, USA
| | - Alireza Meysami
- Department of Rheumatology, Henry Ford Hospital/Wayne State University, Detroit, MI, USA
| | - Ayad H Alkhatib
- Department of Rheumatology, Henry Ford Hospital/Wayne State University, Detroit, MI, USA
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19
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Santamaria-Alza Y, Sanchez-Bautista J, Fajardo-Rivero JE, Figueroa Pineda CL. Acute respiratory involvement in Colombian patients with systemic lupus erythematosus undergoing chest computed tomography. Int J Rheum Dis 2019; 22:1825-1831. [PMID: 31496073 DOI: 10.1111/1756-185x.13686] [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: 10/09/2018] [Revised: 07/28/2019] [Accepted: 08/04/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is an inflammatory disease which affects multiple organs. The respiratory system is compromised in 1.6% to 36% of the patients with SLE. The objective of this study was to know the prevalence of these alterations, their associated variables, and outcomes in patients with SLE between 2012 and 2017. METHODS A cross-sectional study of 200 patients with SLE underwent chest computed tomography (CT). The primary outcome was acute respiratory involvement (ARI). A descriptive, bivariate and multivariate analysis were performed using Stata 12.0 software. RESULTS ARI was present in 40% of the SLE patients undergoing chest CT. The most frequent ARI was pleural effusion in 33%, followed by pneumonia (16.5%), lupus pneumonitis (9%), pulmonary embolism (3%) and pulmonary hemorrhage (2.5%). In bivariate and multivariate analysis a statistically significant association between ARI and nephropathy, hematological impairment, active disease, dead, readmission and prolonged hospital stay was found. CONCLUSION This is the first Colombian study that evaluates ARI in patients with SLE. ARI is an important and frequent condition in patients with SLE, pleural effusion being the most prevalent cause of ARI. There are some variables (nephropathy, hematological impairment and activity disease) that are associated with ARI and could be the basis of intervention.
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Abstract
PURPOSE OF REVIEW Diffuse alveolar hemorrhage (DAH) is a rare but devastating manifestation of antiphospholipid syndrome (APS) patients with or without other systemic autoimmune diseases. Data regarding diagnosis and treatment are limited to case series. We review diagnostic and therapeutic strategies employed in APS patients with DAH and discuss our experience in managing these complex patients. RECENT FINDINGS Pulmonary capillaritis likely contributes to the pathogenesis, however is only observed in half of the biopsies. Corticosteroids induce remission in the majority of patients, however almost half recur and require a steroid-sparing immunosuppressive to maintain remission. Cyclophosphamide- or rituximab-based regimens achieve the highest remission rates (50%); other strategies include intravenous immunoglobulin, plasmapheresis, mycophenolate mofetil, and/or azathioprine. Given the rarity of DAH in APS, treatment is guided by interdisciplinary experience. Why certain patients achieve full remission with corticosteroids while others require immunosuppressive agents is unknown; future research should focus on the pathophysiology and optimal management.
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21
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Kusmirek JE, Kanne JP. Thoracic Manifestations of Connective Tissue Diseases. Semin Ultrasound CT MR 2019; 40:239-254. [DOI: 10.1053/j.sult.2018.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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22
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Pulmonary manifestations in systemic lupus erythematosus: pleural involvement, acute pneumonitis, chronic interstitial lung disease and diffuse alveolar hemorrhage. ACTA ACUST UNITED AC 2019; 14:294-300. [PMID: 29773465 DOI: 10.1016/j.reuma.2018.03.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/28/2018] [Accepted: 03/22/2018] [Indexed: 12/29/2022]
Abstract
Systemic lupus erythematosus is the diffuse autoimmune connective tissue disease that most frequently involves pulmonary involvement, affecting 20% of 90% of the patients. The percentage varies depending on the defining criteria (symptoms, pulmonary tests or histopathological studies). At least once during the disease course, 50% of those affected have pleural and/or pulmonary manifestations, which are associated with higher morbidity and mortality. Pulmonary involvement has no correlation with lupus activity biomarkers, and it is necessary to rule out infectious processes in the initial approach. Bacterial infection is most frequently the cause of lung involvement in lupus and is one of the most important causes of death. Pulmonary involvement is considered to be primary when it is associated with disease activity, and secondary when other causes participate. Drugs have been reported to be associated with pulmonary damage, including interstitial disease. The incidence of malignant lung diseases is increased in systemic lupus erythematosus. Treatment depends on the type and severity of pulmonary involvement.
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23
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Mira-Avendano I, Abril A, Burger CD, Dellaripa PF, Fischer A, Gotway MB, Lee AS, Lee JS, Matteson EL, Yi ES, Ryu JH. Interstitial Lung Disease and Other Pulmonary Manifestations in Connective Tissue Diseases. Mayo Clin Proc 2019; 94:309-325. [PMID: 30558827 DOI: 10.1016/j.mayocp.2018.09.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/24/2018] [Accepted: 09/17/2018] [Indexed: 12/22/2022]
Abstract
Lung involvement in connective tissue diseases is associated with substantial morbidity and mortality, most commonly in the form of interstitial lung disease, and can occur in any of these disorders. Patterns of interstitial lung disease in patients with connective tissue disease are similar to those seen in idiopathic interstitial pneumonias, such as idiopathic pulmonary fibrosis. It may be difficult to distinguish between the 2 ailments, particularly when interstitial lung disease presents before extrapulmonary manifestations of the underlying connective tissue disease. There are important clinical implications in achieving this distinction. Given the complexities inherent in the management of these patients, a multidisciplinary evaluation is needed to optimize the diagnostic process and management strategies. The aim of this article was to summarize an approach to diagnosis and management based on the opinion of experts on this topic.
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Affiliation(s)
- Isabel Mira-Avendano
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL.
| | - Andy Abril
- Division of Rheumatology, Mayo Clinic, Jacksonville, FL
| | - Charles D Burger
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Paul F Dellaripa
- Division of Rheumatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Aryeh Fischer
- Department of Medicine, University of Colorado, Denver, Aurora, CO
| | - Michael B Gotway
- Division of Cardiothoracic Radiology, Mayo Clinic, Scottsdale, AZ
| | - Augustine S Lee
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Joyce S Lee
- Department of Medicine, University of Colorado, Denver, Aurora, CO
| | - Eric L Matteson
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN
| | - Eunhee S Yi
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Masoodi I, Sirwal IA, Anwar SK, Alzaidi A, Balbaid KA. Predictors of Mortality in Pulmonary Haemorrhage during SLE: A Single Centre Study Over Eleven Years. Open Access Maced J Med Sci 2019; 7:92-96. [PMID: 30740168 PMCID: PMC6352490 DOI: 10.3889/oamjms.2019.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/22/2018] [Accepted: 01/10/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Pulmonary haemorrhage (PH) is a serious complication during Systemic Lupus Erythematosus (SLE). AIM The aim was to present data on 12 patients of SLE with classic symptoms and signs of PH admitted throughout eleven years. METHODS This retrospective study was carried out at King Abdul Aziz Specialist hospital in Taif-a tertiary care hospital in the western region of Saudi Arabia. The data was analysed from the case files of SLE patients who had episodes of PH throughout 11 years (January 2007 to December 2017). RESULTS Twelve patients (10 females and 2 males) were found to have diffuse pulmonary haemorrhage during their SLE in the study period. Of 12 patients with confirmed pulmonary haemorrhage (hemoptysis, hypoxemia, new infiltrates on chest radiography, fall in haemoglobin and hemorrhagic returns of bronchoalveolar lavage with hemosiderin-laden macrophages) 4 patients had PH as the first presentation of SLE and 8 patients developed this complication during the disease. All patients presented with shortness of breath and hemoptysis. The most common extra-pulmonary involvement in the study cohort was renal (83%), which ranged from clinical nephritis, nephrotic syndrome to acute renal failure. All patients were managed in intensive care of the hospital, and of 12 patients, 9 (75%) required mechanical ventilation. All patients were uniformly treated with pulse Methylprednisolone; 9 received Cyclophosphamide, 6 received IVIG, and 4 received Plasmapheresis. Only 3 patients (25%) survived despite maximum possible support during their mean hospital stay of 18 ± 5 days. CONCLUSION The requirement of mechanical ventilation and the association of renal and neuropsychiatric complications predicted mortality in patients with pulmonary haemorrhage.
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Affiliation(s)
- Ibrahim Masoodi
- Department of Medicine, College of Medicine, Taif University, Saudi Arabia
| | - Irshad A Sirwal
- Department of Nephrology, King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia
| | - Shaikh Khurshid Anwar
- Department of Pulmonary Medicine, King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia
| | - Ahmed Alzaidi
- Department of Nephrology, King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia
| | - Khalid A Balbaid
- Department of Nephrology, King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia
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Sun YS, Huang DF, Lin FC, Hsu CK, Sun IT, Chang SC, Tsai CY, Lai CC. Cytomegaloviral or Pneumocystis Jiroveci Pneumonia Increases Mortality in Systemic Lupus Erythematosus Patients with Pulmonary Hemorrhage: Evidence from Bronchoalveolar Lavage Fluid. J Rheumatol 2018; 46:251-258. [PMID: 30504509 DOI: 10.3899/jrheum.180104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the role of cytomegaloviral or Pneumocystis jiroveci pneumonia (CMV/PJP) in systemic lupus erythematosus (SLE) patients with pulmonary hemorrhage (PH). METHODS We retrospectively examined hospital records for 27 SLE patients with PH who received bronchoalveolar lavage fluid (BALF) analyses. Clinical profile and mortality rates were compared between groups with and without CMV/PJP. Risk factors for PH-related mortality were analyzed. RESULTS Among 27 SLE patients with PH, 15 had pathogens from BALF samples, and 8 had CMV/PJP. Although CMV/PJP was treated, the RR for 90- and 180-day mortality rates of SLE patients with CMV/PJP were higher than those without these infections (5.94, 95% CI 1.44-24.48; 7.13, 95% CI 1.81-28.06, respectively). Risk factors for 90- and 180-day mortality were presence of CMV/PJP (OR 14.2, 95% CI 1.83-109.9; OR 25.5, 95% CI 2.91-223.3, respectively) and use of pulse methylprednisolone for PH treatment (OR 12.0, 95% CI 1.48-97.2; OR 8.5, 95% CI 1.13-63.9, respectively). Factors increasing the 90-day mortality rate were duration of mechanical ventilation exceeding 14 days (OR 11.1, 95% CI 1.11-112.0) and use of aggressive immunosuppression close to PH onset (OR 7.56, 95% CI 1.09-52.4). Three of the 7 patients receiving aggressive immunosuppression died with the presence of CMV/PJP. CONCLUSION Owing to the high prevalence of CMV/PJP and its association with mortality, routine BALF analysis is recommended for all suitable SLE patients with PH. Use of aggressive immunosuppression does not benefit SLE patients with opportunistic infections during PH attack.
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Affiliation(s)
- Yi-Syuan Sun
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - De-Feng Huang
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - Fang-Chi Lin
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - Chih-Kai Hsu
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - I-Ting Sun
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - Shi-Chuan Chang
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - Chang-Youh Tsai
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - Chien-Chih Lai
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan. .,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University.
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Wang CR, Liu MF, Weng CT, Lin WC, Li WT, Tsai HW. Systemic lupus erythematosus-associated diffuse alveolar haemorrhage: a single-centre experience in Han Chinese patients. Scand J Rheumatol 2018; 47:392-399. [PMID: 29916287 DOI: 10.1080/03009742.2017.1420817] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Despite aggressive therapeutic regimens, diffuse alveolar haemorrhage (DAH) is still associated with a high mortality rate in systemic lupus erythematosus (SLE). This study was carried out in patients with SLE-associated DAH with a focus on their therapeutic modality. METHOD A retrospective review was performed in 839 Han Chinese lupus patients hospitalized for their DAH manifestation from May 2006 to December 2016. RESULTS There were 24 episodes in 17 cases (2.0% incidence), 15 females and two males aged 19-67 years (mean ± sd 38.2 ± 15.1 years). High disease activity [Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) 12-31, 19.8 ± 5.6] was found at the onset of DAH. All patients were treated with high-dose corticosteroid, followed by pulse methylprednisolone (70.6%), plasmapheresis (41.2%), pulse cyclophosphamide (35.3%), and rituximab (23.5%). Six patients (35.3%), including three with extracorporeal membrane oxygenation, died owing to acute respiratory failure. All patients receiving rituximab treatment survived with a follow-up period of 12-58 months (40.8 ± 21.1 months), and no further relapse was noted in three cases with a history of recurrent DAH episodes. In addition, there was a significant decrease in their lupus activity (SLEDAI-2K 21.5 ± 6.0 to 6.3 ± 1.7, p = 0.0286). CONCLUSION In this single-centre series with SLE-associated DAH in Han Chinese patients, a beneficial effect of rituximab therapy was observed.
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Affiliation(s)
- C-R Wang
- a Section of Rheumatology , National Cheng Kung University Hospital , Tainan , Taiwan
| | - M-F Liu
- a Section of Rheumatology , National Cheng Kung University Hospital , Tainan , Taiwan
| | - C-T Weng
- a Section of Rheumatology , National Cheng Kung University Hospital , Tainan , Taiwan
| | - W-C Lin
- b Section of Critical Care Medicine, Department of Internal Medicine , National Cheng Kung University Hospital , Tainan , Taiwan
| | - W-T Li
- b Section of Critical Care Medicine, Department of Internal Medicine , National Cheng Kung University Hospital , Tainan , Taiwan
| | - H-W Tsai
- c Department of Pathology , National Cheng Kung University Hospital , Tainan , Taiwan
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Severe Progressive Diffuse Alveolar Hemorrhage in a Patient with Systemic Lupus Erythematosus. Case Rep Crit Care 2018; 2018:9790459. [PMID: 29984006 PMCID: PMC6011174 DOI: 10.1155/2018/9790459] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/16/2018] [Indexed: 12/25/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) refers to the effusion of blood into the alveoli due to damaged pulmonary microvasculature. The ensuing alveolar collapse can lead to severe hypoxemia with poor prognosis. In these cases, it is crucial to provide respiratory care for hypoxemia in addition to treating the underlying disease. Here, we describe our experience with a case involving a 46-year-old woman with severe DAH-induced hypoxemia accompanying systemic lupus erythematosus (SLE). Mechanical ventilation was managed using airway pressure release ventilation (APRV) after intubation. Through APRV-based respiratory care and treatment of the underlying disease, hemoptysis was eliminated and oxygenation improved. The patient did not experience significant barotrauma and was successfully weaned from mechanical ventilation after 25 days in the intensive care unit. This case demonstrates that APRV-based control for respiratory management can inhibit the effusion of blood into the alveoli and achieve mechanical hemostasis, as well as mitigate alveolar collapse. APRV may be a useful method for respiratory care in patients with severe DAH-induced hypoxemia.
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Lung Involvements in Rheumatic Diseases: Update on the Epidemiology, Pathogenesis, Clinical Features, and Treatment. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6930297. [PMID: 29854780 PMCID: PMC5964428 DOI: 10.1155/2018/6930297] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/27/2018] [Indexed: 01/25/2023]
Abstract
Lung illness encountered in patients with rheumatic diseases bears clinical significance in terms of increased morbidity and mortality as well as potential challenges placed on patient care. Although our understanding of natural history of this important illness is still limited, epidemiologic knowledge has been accumulated during the past decade to provide useful information on the risk factors and prognosis of lung involvements in rheumatic diseases. Moreover, the pathogenesis particularly in the context of genetics has been greatly updated for both the underlying rheumatic disease and associated lung involvement. This review will focus on the current update on the epidemiologic and genetics features and treatment options of the lung involvements associated with four major rheumatic diseases (rheumatoid arthritis, systemic sclerosis, myositis, and systemic lupus erythematosus), with more attention to a specific form of involvement or interstitial lung disease.
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29
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Han S, Zhuang H, Shumyak S, Wu J, Xie C, Li H, Yang LJ, Reeves WH. Liver X Receptor Agonist Therapy Prevents Diffuse Alveolar Hemorrhage in Murine Lupus by Repolarizing Macrophages. Front Immunol 2018; 9:135. [PMID: 29456535 PMCID: PMC5801423 DOI: 10.3389/fimmu.2018.00135] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/16/2018] [Indexed: 12/20/2022] Open
Abstract
The generation of CD138+ phagocytic macrophages with an alternative (M2) phenotype that clear apoptotic cells from tissues is defective in lupus. Liver X receptor-alpha (LXRα) is an oxysterol-regulated transcription factor that promotes reverse cholesterol transport and alternative (M2) macrophage activation. Conversely, hypoxia-inducible factor 1-α (HIF1α) promotes classical (M1) macrophage activation. The objective of this study was to see if lupus can be treated by enhancing the generation of M2-like macrophages using LXR agonists. Peritoneal macrophages from pristane-treated mice had an M1 phenotype, high HIFα-regulated phosphofructokinase and TNFα expression (quantitative PCR, flow cytometry), and low expression of the LXRα-regulated gene ATP binding cassette subfamily A member 1 (Abca1) and Il10 vs. mice treated with mineral oil, a control inflammatory oil that does not cause lupus. Glycolytic metabolism (extracellular flux assays) and Hif1a expression were higher in pristane-treated mice (M1-like) whereas oxidative metabolism and LXRα expression were higher in mineral oil-treated mice (M2-like). Similarly, lupus patients’ monocytes exhibited low LXRα/ABCA1 and high HIF1α vs. controls. The LXR agonist T0901317 inhibited type I interferon and increased ABCA1 in lupus patients’ monocytes and in murine peritoneal macrophages. In vivo, T0901317 induced M2-like macrophage polarization and protected mice from diffuse alveolar hemorrhage (DAH), an often fatal complication of lupus. We conclude that end-organ damage (DAH) in murine lupus can be prevented using an LXR agonist to correct a macrophage differentiation abnormality characteristic of lupus. LXR agonists also decrease inflammatory cytokine production by human lupus monocytes, suggesting that these agents may be have a role in the pharmacotherapy of lupus.
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Affiliation(s)
- Shuhong Han
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Florida, Gainesville, FL, United States
| | - Haoyang Zhuang
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Florida, Gainesville, FL, United States
| | - Stepan Shumyak
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Florida, Gainesville, FL, United States
| | - Jingfan Wu
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Florida, Gainesville, FL, United States
| | - Chao Xie
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL, United States
| | - Hui Li
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL, United States
| | - Li-Jun Yang
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL, United States
| | - Westley H Reeves
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Florida, Gainesville, FL, United States
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A fatal case of diffuse alveolar hemorrhage as the initial presentation of systemic lupus erythematosus: A case report and literature review. Respir Med Case Rep 2018; 24:55-57. [PMID: 29977760 PMCID: PMC6010613 DOI: 10.1016/j.rmcr.2018.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 04/12/2018] [Accepted: 04/12/2018] [Indexed: 02/04/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare fatal pulmonary complication of systemic lupus erythematosus (SLE). The clinical syndrome is characterized by hemoptysis, acute fall in hematocrit, hypoxemic respiratory failure, and diffuses pulmonary infiltrates. We describe a case of 23-year-old female who presented with Ludwig's angina that was complicated by diffuse alveolar hemorrhage as the initial presentation of undiagnosed systemic lupus erythematosus. A high index of suspicion is need for prompt diagnosis and treatment in order to avoid the high mortality associated with such cases.
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Martínez-Martínez MU, Oostdam DAHV, Abud-Mendoza C. Diffuse Alveolar Hemorrhage in Autoimmune Diseases. Curr Rheumatol Rep 2017; 19:27. [PMID: 28397125 DOI: 10.1007/s11926-017-0651-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The present paper establishes a narrative and analytical review of diffuse alveolar hemorrhage (DAH) in ANCA-associated vasculitis, systemic lupus erythematosus, and antiphospholipid syndrome. RECENT FINDINGS Recent studies found a frequent association between DAH and infections and systemic lupus erythematosus and its associated factors. Biological therapies like rituximab have demonstrated benefit mainly in patients with ANCA-associated vasculitis. Main clinical manifestations of diffuse alveolar hemorrhage in these three diseases include dyspnea, pulmonary infiltrates, cough, and hypoxemia. The presence of hemorrhagic bronchoalveolar lavage, hemosiderin containing macrophages, or an increase of carbon monoxide diffusing capacity have been described in some series as helpful findings for the diagnosis. Hemoptysis has been seen mainly in systemic lupus erythematosus. The cornerstone of therapy includes glucocorticoids and cyclophosphamide, and recent findings in ANCA-associated vasculitis suggest the similar benefit of rituximab. Future evaluations and systematic reviews will help to define the real benefit for therapies that appeared to be controversial at the moment.
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Affiliation(s)
- Marco Ulises Martínez-Martínez
- Faculty of Medicine, Universidad Autónoma San Luis Potosí and Hospital Central "Dr. Ignacio Morones Prieto", Avenida Venustiano Carranza 2395, Zona Universitaria, 78290, San Luis Potosí, San Luis Potosí, Mexico
- Hospital General de Zona No. 1, Instituto Mexicano del Seguro Social, San Luis Potosí, San Luis Potosí, Mexico
| | - David Alejandro Herrera-van Oostdam
- Faculty of Medicine, Universidad Autónoma San Luis Potosí and Hospital Central "Dr. Ignacio Morones Prieto", Avenida Venustiano Carranza 2395, Zona Universitaria, 78290, San Luis Potosí, San Luis Potosí, Mexico
- Hospital General de Zona No. 50, Instituto Mexicano del Seguro Social, San Luis Potosí, San Luis Potosí, Mexico
| | - Carlos Abud-Mendoza
- Faculty of Medicine, Universidad Autónoma San Luis Potosí and Hospital Central "Dr. Ignacio Morones Prieto", Avenida Venustiano Carranza 2395, Zona Universitaria, 78290, San Luis Potosí, San Luis Potosí, Mexico.
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Quadrelli S, Dubinsky D, Solis M, Yucra D, Hernández M, Karlen H, Brigante A. Immune diffuse alveolar hemorrhage: Clinical presentation and outcome. Respir Med 2017; 129:59-62. [DOI: 10.1016/j.rmed.2017.06.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/11/2017] [Accepted: 06/03/2017] [Indexed: 12/12/2022]
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Kim D, Choi J, Cho SK, Choi CB, Kim TH, Jun JB, Yoo DH, Bae SC, Sung YK. Clinical characteristics and outcomes of diffuse alveolar hemorrhage in patients with systemic lupus erythematosus. Semin Arthritis Rheum 2017; 46:782-787. [DOI: 10.1016/j.semarthrit.2016.09.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 09/05/2016] [Accepted: 09/08/2016] [Indexed: 02/06/2023]
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Zhuang H, Han S, Lee PY, Khaybullin R, Shumyak S, Lu L, Chatha A, Afaneh A, Zhang Y, Xie C, Nacionales D, Moldawer L, Qi X, Yang LJ, Reeves WH. Pathogenesis of Diffuse Alveolar Hemorrhage in Murine Lupus. Arthritis Rheumatol 2017; 69:1280-1293. [PMID: 28217966 DOI: 10.1002/art.40077] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 02/14/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Diffuse alveolar hemorrhage (DAH) in lupus patients confers >50% mortality, and the cause is unknown. We undertook this study to examine the pathogenesis of DAH in C57BL/6 mice with pristane-induced lupus, a model of human lupus-associated DAH. METHODS Clinical/pathologic and immunologic manifestations of DAH in pristane-induced lupus were compared with those of DAH in humans. Tissue distribution of pristane was examined by mass spectrometry. Cell types responsible for disease were determined by in vivo depletion using clodronate liposomes and antineutrophil monoclonal antibodies (anti-Ly-6G). The effect of complement depletion with cobra venom factor (CVF) was examined. RESULTS After intraperitoneal injection, pristane migrated to the lung, causing cell death, small vessel vasculitis, and alveolar hemorrhage similar to that seen in DAH in humans. B cell-deficient mice were resistant to induction of DAH, but susceptibility was restored by infusing IgM. C3-/- and CD18-/- mice were also resistant, and DAH was prevented in wild-type mice by CVF. Induction of DAH was independent of Toll-like receptors, inflammasomes, and inducible nitric oxide. Mortality was increased in interleukin-10 (IL-10)-deficient mice, and pristane treatment decreased IL-10 receptor expression in monocytes and STAT-3 phosphorylation in lung macrophages. In vivo neutrophil depletion was not protective, while treatment with clodronate liposomes prevented DAH, which suggests that macrophage activation is central to DAH pathogenesis. CONCLUSION The pathogenesis of DAH involves opsonization of dead cells by natural IgM and complement followed by complement receptor-mediated lung inflammation. The disease is macrophage dependent, and IL-10 is protective. Complement inhibition and/or macrophage-targeted therapies may reduce mortality in lupus-associated DAH.
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Affiliation(s)
| | | | - Pui Y Lee
- Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Li Lu
- University of Florida, Gainesville
| | | | | | | | - Chao Xie
- University of Florida, Gainesville
| | | | | | - Xin Qi
- University of Florida, Gainesville
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Diffuse Alveolar Hemorrhage in Systemic Lupus Erythematosus: Histopathologic Features and Clinical Correlations. Case Rep Pathol 2017; 2017:1936282. [PMID: 28536665 PMCID: PMC5425825 DOI: 10.1155/2017/1936282] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/28/2017] [Accepted: 04/10/2017] [Indexed: 12/04/2022] Open
Abstract
The case of a 16-year-old African-American girl with systemic lupus erythematosus, who developed diffuse alveolar hemorrhage with fatal consequences, is described. Diffuse alveolar hemorrhage is a rare but serious complication of systemic lupus. It occurs in three distinct but overlapping phenotypes, acute capillaritis, bland pulmonary hemorrhage, and diffuse alveolar damage, each of which is associated with a different group of underlying conditions. Diffuse alveolar hemorrhage is a medical emergency: choice of treatment depends on early diagnosis and determination of the underlying etiology. Acute infection, superimposed on diffuse alveolar hemorrhage in the setting of immune compromise, is often a terminal event, as in this case.
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Singla S, Canter DL, Vece TJ, Muscal E, DeGuzman M. Diffuse Alveolar Hemorrhage as a Manifestation of Childhood-Onset Systemic Lupus Erythematosus. Hosp Pediatr 2016; 6:496-500. [PMID: 27390368 DOI: 10.1542/hpeds.2015-0281] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is a devastating clinical syndrome characterized by a falling hematocrit, respiratory insufficiency, and radiographic evidence of pulmonary infiltrates. Literature regarding management of DAH in childhood-onset SLE (cSLE) is limited. METHODS We reviewed the presentation, management, and outcome of DAH in a pediatric tertiary medical center with one of the largest cSLE cohorts in North America. During a 10 year period 7 of 410 children with cSLE had DAH. RESULTS The majority of cSLE patients with DAH were male (71%) and Hispanic (57%). The median age at the time of DAH diagnosis was 14 years (range 3 -15 years). DAH was the presenting manifestation of cSLE in 29% of children; 71% presented with DAH within 3 months of their diagnosis. All patients had cough, 86% had dyspnea, and 29% had hemoptysis. All patients had anemia and 71% had thrombocytopenia. Eighty-six percent had hematuria/proteinuria, and a positive anti-double stranded DNA antibody. Chest imaging showed diffuse ground glass opacities in all events. All patients developed respiratory insufficiency (29% supplemental oxygenation and 71% mechanical ventilation). Transfusions were required in 57% of cases. All patients received corticosteroids and additional immunomodulation to achieve disease control. Eighty-six percent of our DAH/cSLE cohort survived their initial event (median follow-up 2.5 years). No survivor required supplemental oxygen or had a DAH recurrence. CONCLUSIONS SLE should be in the hospitalist's differential diagnosis for any child with respiratory insufficiency, cytopenias, and/or urinary abnormalities. Once cSLE is identified, initiation of aggressive immune suppression with multiple agents may enhance outcomes.
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Affiliation(s)
- Saimun Singla
- Division of Allergy, Immunology, and Rheumatology, Texas Children's Hospital, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas; and
| | - Debra L Canter
- Division of Allergy, Immunology, and Rheumatology, Texas Children's Hospital, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas; and
| | - Timothy J Vece
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; and Division of Pulmonology, Texas Children's Hospital, Houston, Texas
| | - Eyal Muscal
- Division of Allergy, Immunology, and Rheumatology, Texas Children's Hospital, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas; and
| | - Marietta DeGuzman
- Division of Allergy, Immunology, and Rheumatology, Texas Children's Hospital, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas; and
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Finucci Curi P, Pierrestegui M, Ortiz A, Ceccato F, Paira S. Hemorragia pulmonar en pacientes con lupus eritematoso sistémico. Características clínicas y pronóstico. Med Clin (Barc) 2015; 145:375-9. [DOI: 10.1016/j.medcli.2014.07.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/04/2014] [Accepted: 07/07/2014] [Indexed: 10/24/2022]
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Kazzaz NM, Coit P, Lewis EE, McCune WJ, Sawalha AH, Knight JS. Systemic lupus erythematosus complicated by diffuse alveolar haemorrhage: risk factors, therapy and survival. Lupus Sci Med 2015; 2:e000117. [PMID: 26430514 PMCID: PMC4586940 DOI: 10.1136/lupus-2015-000117] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 08/14/2015] [Accepted: 08/28/2015] [Indexed: 01/09/2023]
Abstract
Objectives While diffuse alveolar haemorrhage (DAH) is recognised as a life-threatening complication of systemic lupus erythematosus (SLE), little is known about its risk factors and response to treatment. We describe 22 cases of DAH in a US lupus cohort of approximately 1000 patients, and compare them to 66 controls from the same outpatient cohort. Methods We captured variables pertaining to diagnoses of SLE and secondary antiphospholipid syndrome (APS), and analysed them by univariate testing. Those variables with p values <0.05 were then further considered in a multivariate model. Kaplan-Meier curves were constructed for each group, and survival was analysed by Log-rank test. Results Of the 22 patients with DAH, 59% were diagnosed with DAH within 5 years of lupus diagnosis. By univariate testing, several manifestations of SLE and APS were more common in patients with DAH, including history of thrombocytopenia, cardiac valve disease, low C3, leucopenia, neuropsychiatric features, haemolysis, arterial thrombosis, lupus anticoagulant, secondary APS and low C4. On multivariate analysis, history of thrombocytopenia and low C3 were maintained as independent risk factors. Importantly, only two patients had platelet counts <50 000/µL at the time of the DAH episode, arguing that DAH was not simply a haemorrhagic complication of thrombocytopenia. All patients were treated with increased immunosuppression, including various combinations of corticosteroids, plasmapheresis, cyclophosphamide, rituximab and mycophenolate mofetil. Notably, all patients in the cohort survived their initial episode of DAH. While the patients with DAH did well in the short-term, their long-term survival was significantly worse than controls. Several of the deaths were attributable to thrombotic complications after recovering from DAH. Conclusions To the best of our knowledge, this is the largest case–control study of lupus DAH to date. History of thrombocytopenia was strongly predictive of DAH (OR ∼40). A number of APS manifestations correlated with DAH by univariate analysis, and deserve further consideration in larger studies.
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Affiliation(s)
- Nayef M Kazzaz
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Patrick Coit
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Emily E Lewis
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - W Joseph McCune
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Amr H Sawalha
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Jason S Knight
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
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Gonzalez-Echavarri C, Pernas B, Ugarte A, Ruiz-Irastorza G. Severe multiorganic flare of systemic lupus erythematosus successfully treated with rituximab and cyclophosphamide avoiding high doses of prednisone. Lupus 2014; 23:323-6. [PMID: 24531426 DOI: 10.1177/0961203314520842] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Both acute pancreatitis and diffuse alveolar haemorrhage are rare conditions associated with systemic lupus erythematosus (SLE). In this case report, a 23-year-old female with SLE was diagnosed with lupus-associated pancreatitis and, within a few days and despite initial therapy with pulse methyl-prednisolone, subsequently suffered an acute respiratory failure due to a diffuse alveolar haemorrhage. The patient was admitted to the intensive care unit and treatment was intensified with cyclophosphamide and rituximab, which shortly induced the complete remission of SLE with resolution of both clinical conditions. She completed treatment with six pulses of cyclophosphamide followed by azathioprine, hydroxychloroquine and prednisone at initial doses of 20 mg/d with rapid tapering to 5 mg/d, without relapse of the disease during the following year. This case can illustrate that, even in severe, life-threatening SLE flares, it is possible to avoid high-dose prednisone, which has been associated with severe side effects, including infections. Acute pancreatitis and diffuse alveolar haemorrhage are rare conditions caused by SLE. DAH can be a life-threatening complication, with an early mortality of at least 50%. When facing such severe SLE activity, there is a general tendency to use high doses of prednisone as the initial therapy, maintaining such high doses for long periods of time, even after the clinical situation has subsided. We report a case of a young woman with SLE, suffering from acute pancreatitis and diffuse alveolar haemorrhage, who was successfully treated with pulse methyl-prednisolone, hydroxychloroquine, cyclophosphamide and rituximab, combined with medium doses of prednisone.
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Affiliation(s)
- C Gonzalez-Echavarri
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Health Research Institute, Hospital Universitario Cruces, University of The Basque Country, Spain
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Martinez-Martinez MU, Sturbaum AK, Alcocer-Varela J, Merayo-Chalico J, Gómez-Martin D, Gómez-Bañuelos JDJE, Saavedra MÁ, Enciso-Peláez S, Faugier-Fuentes E, Maldonado-Velázquez R, Suárez-Larios LM, Vega-Morales D, Casasola-Vargas JC, Carrillo Pérez DL, Abril A, Butendieck R, Irazoque-Palazuelos F, Abud-Mendoza C. Factors associated with mortality and infections in patients with systemic lupus erythematosus with diffuse alveolar hemorrhage. J Rheumatol 2014; 41:1656-61. [PMID: 24986849 DOI: 10.3899/jrheum.130927] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate factors associated with mortality and infections in patients with systemic lupus erythematosus (SLE) and diffuse alveolar hemorrhage (DAH). METHODS A retrospective chart review was carried out for medical admissions of patients with a diagnosis of SLE and DAH in 9 hospitals. Clinical and laboratory data were recorded for each patient at DAH diagnosis. RESULTS We included 57 episodes of DAH of 50 patients (7 recurrences), 49 women (86%), 14 juvenile SLE (24.6%); 24 had died (42.1%). In the chart review we detected infection in 22 episodes (38.6%): 8 invasive fungal infections, 16 bacterial infections, and 2 patients had both types. In the bivariate analysis, factors associated with mortality were high Acute Physiology and Chronic Health Evaluation II scores, requirement of mechanical ventilation (OR 15.0, 95% CI 1.9 to 662.2), infections (fungal or bacterial; OR 3.2, CI 0.9 to 11.1), renal failure (OR 4.9, CI 1.4 to 18.0), and thrombocytopenia (OR 4.3, CI 1.2 to 15.6). We found similar mortality between children and adults. Infections were associated with treatment for SLE, requirement of mechanical ventilation, hypocomplementemia, and high levels of C-reactive protein. CONCLUSION Infection is a frequent finding in patients with DAH and SLE; we found similar mortality between adult SLE and juvenile SLE. Factors that we describe associated with infections may influence the therapeutic selection for these patients.
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Affiliation(s)
- Marco Ulises Martinez-Martinez
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Anne K Sturbaum
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Jorge Alcocer-Varela
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Javier Merayo-Chalico
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Diana Gómez-Martin
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - José de Jesús Eduardo Gómez-Bañuelos
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Miguel Ángel Saavedra
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Sandra Enciso-Peláez
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Enrique Faugier-Fuentes
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Rocío Maldonado-Velázquez
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Luz María Suárez-Larios
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - David Vega-Morales
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Julio César Casasola-Vargas
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Diego Luis Carrillo Pérez
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Andy Abril
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Ronald Butendieck
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Fedra Irazoque-Palazuelos
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto"
| | - Carlos Abud-Mendoza
- From the Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosi, S.L.P.; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS) México D.F.; Hospital Infantil de México, Mexico City; Hospital Infantil del Estado de Sonora, Hermosillo, Sonora; Hospital Universitario de Nuevo León, Monterrey, Nuevo León; Hospital General de México, México D.F.; Hospital 20 de Noviembre ISSSTE, Mexico City, Mexico; Mayo Clinic, Jacksonville, Florida, USA.M.U. Martinez-Martinez, MD; A.K. Sturbaum, MD, Hospital Central "Dr. Ignacio Morones Prieto"; J. Alcocer-Varela, MD; J. Merayo-Chalico, MD; D. Gómez-Martin, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.D.J.E. Gómez-Bañuelos, MD; M.Á. Saavedra, MD, Centro Médico Nacional "La Raza", IMSS; S. Enciso-Peláez, MD; E. Faugier-Fuentes, MD; R. Maldonado-Velázquez, MD, Hospital Infantil de México; L.M. Suárez-Larios, MD, Hospital Infantil del Estado de Sonora; D. Vega-Morales, MD, Hospital Universitario de Nuevo León; J.C. Casasola-Vargas, MD, Hospital General de México; D.L. Carrillo Pérez, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; A. Abril, MD; R. Butendieck, MD, Mayo Clinic Jacksonville; F. Irazoque-Palazuelos, MD, Hospital 20 de Noviembre ISSSTE; C. Abud-Mendoza, MD, Hospital Central "Dr. Ignacio Morones Prieto".
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Hemorragia alveolar difusa en pacientes con lupus eritematoso sistémico. Manifestaciones clínicas, tratamiento y pronóstico. ACTA ACUST UNITED AC 2014; 10:248-53. [DOI: 10.1016/j.reuma.2014.02.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/03/2014] [Accepted: 02/14/2014] [Indexed: 01/08/2023]
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Pego-Reigosa JM, Cobo-Ibáñez T, Calvo-Alén J, Loza-Santamaría E, Rahman A, Muñoz-Fernández S, Rúa-Figueroa Í. Efficacy and safety of nonbiologic immunosuppressants in the treatment of nonrenal systemic lupus erythematosus: a systematic review. Arthritis Care Res (Hoboken) 2014; 65:1775-85. [PMID: 23609987 DOI: 10.1002/acr.22035] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 03/27/2013] [Accepted: 04/12/2013] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To analyze the efficacy and safety of nonbiologic immunosuppressants in the treatment of nonrenal systemic lupus erythematosus (SLE). METHODS We conducted a sensitive literature search in Medline, Embase, and the Cochrane Central Register of Controlled Trials up to October 2011. The selection criteria were studies including adult patients with SLE, a treatment intervention with nonbiologic immunosuppressants, a placebo or active comparator group, and outcome measures assessing efficacy and/or safety. Meta-analyses, systematic reviews, clinical trials, and cohort studies were included. The quality of each study was evaluated using Jadad’s scale and the Oxford Levels of Evidence. RESULTS In total, 158 of the 2,827 initially found articles were selected for detailed review; 65 studies fulfilled the predetermined criteria. Overall, the studies were low quality, with only 11 randomized controlled trials (RCTs). Cyclophosphamide demonstrated efficacy for neuropsychiatric SLE, preventing relapses with an additional steroid sparing effect, although its use was associated with cumulative damage, development of cervical intraepithelial neoplasia,and ovarian failure. Other immunosuppressants (azathioprine, methotrexate, leflunomide, mycophenolate mofetil,and cyclosporin A) demonstrated efficacy in reducing nonrenal activity and flares with a steroid-sparing effect, although only on occasion in non–placebo-controlled RCTs of small numbers of patients. CONCLUSION Several immunosuppressants demonstrated their safety and efficacy in nonrenal SLE. A specific drug for each particular manifestation cannot be recommended, although cyclophosphamide may be used in more severe cases, and methotrexate may be the first option in most cases of moderately active SLE. High-quality RCTs of larger numbers of patients are needed.
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Pacheco Claudio C, Charbonney E, Durand M, Kolan C, Laskine M. Extracorporeal membrane oxygenation in diffuse alveolar hemorrhage secondary to systemic lupus erythematosus. J Clin Med Res 2014; 6:145-8. [PMID: 24578757 PMCID: PMC3935524 DOI: 10.14740/jocmr1685w] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2013] [Indexed: 11/15/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare and potentially deadly complication of systemic lupus erythematosus (SLE). We report two adult cases where extracorporeal membrane oxygenation (ECMO) was used as rescue therapy for severe respiratory failure in this setting. We discuss the risk related to coagulation disturbance and the need for the circuit anticoagulation in this particular setting. We also briefly discuss the clinical problem of lack of knowledge on the bioavailability of the immunosuppressive treatment with the use of ECMO. We think that ECMO should be used as rescue therapy in patients with DAH caused by SLE, but strategies for anticoagulation require further precision.
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Affiliation(s)
| | - Emmanuel Charbonney
- Hopital de Trois-Rivieres and Hopital du Sacre-Coeur de Montreal, Montreal, Canada
| | - Madeleine Durand
- Department of Medicine, Hopital Hotel-Dieu, CRCHUM, Montreal, Canada
| | - Christophe Kolan
- Department of Medicine, Hopital Hotel-Dieu, CRCHUM, Montreal, Canada
| | - Mikhael Laskine
- Department of Medicine, Hopital Hotel-Dieu, CRCHUM, Montreal, Canada
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Lai CC, Chen WS, Chang YS, Wang SH, Huang CJ, Guo WY, Yang WC, Huang DF. Clinical Features and Outcomes of Posterior Reversible Encephalopathy Syndrome in Patients With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2013; 65:1766-74. [DOI: 10.1002/acr.22047] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 04/25/2013] [Accepted: 05/01/2013] [Indexed: 12/22/2022]
Affiliation(s)
- Chien-Chih Lai
- Taipei Veterans General Hospital, Taiwan and National Yang-Ming University; Taipei Taiwan
| | - Wei-Sheng Chen
- Taipei Veterans General Hospital, Taiwan and National Yang-Ming University; Taipei Taiwan
| | - Yu-Sheng Chang
- Shuang Ho Hospital, Taipei Medical University, New Taipei City, and National Yang-Ming University; Taipei Taiwan
| | - Shu-Hung Wang
- Taipei Veterans General Hospital, Taiwan and National Yang-Ming University; Taipei Taiwan
| | - Chun-Jui Huang
- Taipei Veterans General Hospital, Taiwan and National Yang-Ming University; Taipei Taiwan
| | - Wan-Yuo Guo
- Taipei Veterans General Hospital; Taipei Taiwan
| | | | - De-Feng Huang
- Taipei Veterans General Hospital, Taiwan and National Yang-Ming University; Taipei Taiwan
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Martínez-Martínez MU, Abud-Mendoza C. Recurrent diffuse alveolar haemorrhage in a patient with systemic lupus erythematosus: long-term benefit of rituximab. Lupus 2012; 21:1124-1127. [DOI: 10.1177/0961203312444171] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Diffuse alveolar haemorrhage (DAH) is an uncommon complication of systemic lupus erythematosus (SLE), and recurrences of DAH with remission periods are unusual. We describe a young woman with cachexia as the initial manifestation of SLE who presented posterior reversible encephalopathy syndrome (PRES), intestinal vasculitis and four episodes of DAH even though she was receiving combined immune suppressive therapy. After treatment with rituximab (RTX) the patient has not presented further episodes of DAH.
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Affiliation(s)
- MU Martínez-Martínez
- Regional Unit of Rheumatology and Osteoporosis, Central Hospital “Dr. Ignacio Morones Prieto” and Faculty of Medicine, Universidad Autónoma de San Luis Potosí, México
| | - C Abud-Mendoza
- Regional Unit of Rheumatology and Osteoporosis, Central Hospital “Dr. Ignacio Morones Prieto” and Faculty of Medicine, Universidad Autónoma de San Luis Potosí, México
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Shi D, Wang D, Li X, Zhang H, Che N, Lu Z, Sun L. Allogeneic transplantation of umbilical cord-derived mesenchymal stem cells for diffuse alveolar hemorrhage in systemic lupus erythematosus. Clin Rheumatol 2012; 31:841-6. [PMID: 22302582 DOI: 10.1007/s10067-012-1943-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 12/21/2011] [Accepted: 01/16/2012] [Indexed: 01/15/2023]
Abstract
Umbilical cord-derived mesenchymal stem cell transplantation (UC-MSCT) has been proved to be effective in the treatment of systemic lupus erythematosus (SLE), based on animal experiments and clinical trials. Diffuse alveolar hemorrhage (DAH) is a rare complication of SLE with a high mortality usually over 50%. This study aimed to assess the efficacy of UC-MSCT in the treatment of SLE-associated DAH. Four SLE patients complicated with DAH, who underwent UC-MSCT, were included. Clinical changes before and after transplantation were assessed by measurements of hemoglobin, platelet level, oxygen saturation, and serological factors. High-resolution CT (HRCT) scans of the chest were performed to evaluate pulmonary manifestation. All the four patients showed dramatic improvements of their clinical manifestations. Hemoglobin was elevated after UC-MSCT and was sustained at a normal level 6 months after UC-MSCT in the four patients. Platelet level was upregulated in two patients who had thrombocytopenia at baseline. Oxygen saturation appeared to be normal at 1 month after UC-MSCT, and this result was confirmed by the HRCT scan of the chest. Serum albumin elevated to 3.5 g/dl 6 months after transplantation. Our findings suggest that UC-MSCT results in amelioration of oxygen saturation as well as hematological and serologic changes, which revealed that UC-MSCT could be applied as a salvage strategy for DAH patients.
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Affiliation(s)
- Dongyan Shi
- Department of Immunology and Rheumatology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, People's Republic of China
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Yongsiri S, Thammakumpee J, Annanon N. SLE with diffuse alveolar hemorrhage, microangiopathic hemolytic anemia and acute renal failure. J Clin Apher 2012; 27:263-4. [PMID: 22730045 DOI: 10.1002/jca.21237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 05/23/2012] [Indexed: 11/11/2022]
Abstract
In SLE patients with diffuse alveolar hemorrhage (DAH) and acute renal failure (ARF), the most common associated renal injury is proliferative lupus nephritis. We report a case of a young SLE patient with DAH and ARF who was successfully treated with a course of therapeutic plasma exchange (TPE) plus pulse IV cyclophosphamide. Kidney biopsy revealed an alternative diagnosis.
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Martínez-Martínez MU, Herrera-Van Oostdam D, Román-Acosta S, Magaña-Aquino M, Baranda-Cándido L, Abud-Mendoza C. Invasive fungal infections in patients with systemic lupus erythematosus. J Rheumatol 2012; 39:1814-8. [PMID: 22707608 DOI: 10.3899/jrheum.111498] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Invasive fungal infections (IFI) are catastrophic diseases associated with a high mortality. Relatively few cases of IFI have been described in systemic lupus erythematosus (SLE) and their related factors have not been completely explored. We evaluated factors associated with IFI in patients with SLE. METHODS All patients with both IFI and SLE admitted to our hospital in the last 7 years were evaluated and each was compared with 5 hospitalized patients with SLE (controls). Demographic factors, duration of SLE, and treatment in the previous month were compared. RESULTS Sixty patients with SLE were evaluated (10 with IFI and 50 controls). Median age was 29 years. High C-reactive protein levels were associated with IFI, along with other factors such as high disease activity, mechanical ventilation, treatment with antibiotics, hemodialysis, high doses of glucocorticoids (GC), and treatment with mycophenolate mofetil. Mortality was 4 times more frequent in patients with IFI than in SLE patients without the deep fungal infection. CONCLUSION IFI is a rare infection observed in patients with rheumatic diseases. We describe factors associated with IFI in patients with SLE. IFI is associated with elevated morbidity and mortality. Early diagnosis and treatment are desirable.
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Affiliation(s)
- Marco Ulises Martínez-Martínez
- Regional Unit of Rheumatology and Osteoporosis, Central Hospital Dr. Ignacio Morones Prieto, and Faculty of Medicine, Universidad Autónoma de San Luis Potosí, Av. V. Carranza 2395, San Luis Potosí, S.L.P., Mexico, 78240
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Araujo DB, Borba EF, Silva CA, Campos LMA, Pereira RMR, Bonfa E, Shinjo SK. Alveolar hemorrhage: distinct features of juvenile and adult onset systemic lupus erythematosus. Lupus 2012; 21:872-7. [DOI: 10.1177/0961203312441047] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We compared outcomes of alveolar hemorrhage (AH) in juvenile (JSLE) and adult onset SLE (ASLE). From 263 JSLE and 1522 ASLE, the AH occurred in 13 (4.9%) and 15 (1.0%) patients, respectively ( p < .001). Both groups had comparable disease duration (2.6 ± 3.0 vs. 5.6 ± 7.0 years, p = .151) and median SLEDAI scores [17.5 (2 to 32) vs. 17.5 (3 to 28), p = 1.000]. At AH onset, a higher frequency of JSLE were already on a high prednisone dose ( > 0.5 mg/kg/day) compared to ASLE (54% vs. 15%, p = .042). The mean drop of hemoglobin was significantly lower in JSLE (2.9 ± 0.9 vs. 5.5 ± 2.9 g/dL, p = .006). Although treatments with methylprednisolone, plasmapheresis, intravenous immunoglobulin and cyclophosphamide were similar in both groups ( p > .050), regarding outcomes, there was a trend in high frequency of mechanical ventilation use (85% vs. 47%, p = .055) and also significant mortality (69% vs. 13%, p = .006) in JSLE compared to ASLE. The sepsis frequency was comparable in both groups (50% vs. 27%, p = .433). We have identified that AH in JSLE has a worse outcome most likely related to respiratory failure. The AH onset in JSLE already treated with high-dose steroids raises the concern of inadequate response to this treatment and reinforces the recommendation of early aggressive alternative therapies in this group of patients.
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Affiliation(s)
- DB Araujo
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
- Rheumatology Department, Hospital do Servidor Público Estadual de São Paulo, Brazil
| | - EF Borba
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - CA Silva
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
- Pediatric Rheumatology Unit, Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - LMA Campos
- Pediatric Rheumatology Unit, Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - RMR Pereira
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - E Bonfa
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - SK Shinjo
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
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