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Frittoli RB, Vivaldo JF, Costallat LTL, Appenzeller S. Gastrointestinal involvement in systemic lupus erythematosus: A systematic review. J Transl Autoimmun 2021; 4:100106. [PMID: 34179742 PMCID: PMC8214088 DOI: 10.1016/j.jtauto.2021.100106] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Gastrointestinal involvement is a common complain observed in 40-60% of systemic lupus erythematosus (SLE) patients. We performed a systematic review of clinically severe and potential life-threatening gastrointestinal manifestations and discuss clinical presentation, pathogenesis and treatment. METHODS We performed a literature search in English literature using PubMed and Embase from 2000 to December 2020. The following MeSH terms: systemic lupus erythematosus, protein-losing enteropathy, ascites, pancreatitis, vasculitis, intestinal vasculitis, enteritis and diarrhea published in the English literature. RESULTS We identified 141 studies (case reports, case series and cohort studies). The most frequent presenting symptoms are acute abdominal pain, nausea, and vomiting. Many of the manifestations were associated with disease activity. Histological features are rarely available, but both vasculitis and thrombosis have been described. There is no treatment guideline. The majority of patients were treated with corticosteroids and the most common immunososupressant were azathioprine, cyclophosphamide and mycophenolate. CONCLUSION Vasculitis and thrombosis may be responsible for severe life-threatening manifestations such as pancreatitis, protein loosing gastroenteritis, acalculous cholecistyitis and enteritis.
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Affiliation(s)
- Renan Bazuco Frittoli
- Post-Graduation in Medical Pathophysiology, School of Medical Science, University of Campinas, Brazil
| | - Jéssica Fernandes Vivaldo
- Graduate Program in Child and Adolescent Health, School of Medical Science, University of Campinas, Brazil
| | - Lilian Tereza Lavras Costallat
- Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science, University of Campinas, Campinas, São Paulo, 13083881, Brazil
| | - Simone Appenzeller
- Department of Medicine, School of Medical Science - State University of Campinas, Campinas, São Paulo, 13083881, Brazil
- Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science, University of Campinas, Campinas, São Paulo, 13083881, Brazil
- Post-Graduation in Medical Pathophysiology, School of Medical Science, University of Campinas, Brazil
- Graduate Program in Child and Adolescent Health, School of Medical Science, University of Campinas, Brazil
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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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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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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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Efficacy of Rituximab in a Systemic Lupus Erythematosus Patient Presenting with Diffuse Alveolar Hemorrhage. Case Rep Rheumatol 2017; 2017:6031053. [PMID: 29259835 PMCID: PMC5705898 DOI: 10.1155/2017/6031053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/17/2017] [Accepted: 10/22/2017] [Indexed: 11/17/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of systemic lupus erythematosus (SLE). Although infrequent, its mortality is very high. While there are no established therapeutic guidelines, DAH has been traditionally managed with high-dose intravenous (IV) corticosteroids, cyclophosphamide, and plasma exchange. The efficacy of alternative therapies such as rituximab has been described only in a few cases. Herein, we report a 25-year-old Hispanic man who presented with acute-onset SLE manifested by polyarthralgia, nephritis, seizures, pancytopenia, severe hypocomplementemia, and elevated anti-dsDNA antibodies. His disease course was complicated by DAH. His condition was refractory to high-dose intravenous (IV) methylprednisolone pulses, IV cyclophosphamide, and plasmapheresis. Given the lack of clinical response, he was started on IV rituximab 375 mg/m2 weekly for a total of four courses. He rapidly improved after the first two doses. Over the next seven months, he did not present recurrent pulmonary symptoms. Follow-up chest computed tomography did not show residual abnormalities. This case, together with other reports, suggests that rituximab is an effective therapeutic option for DAH in SLE.
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Papiris SA, Manali ED, Kolilekas L, Kagouridis K, Maniati M, Filippatos G, Bouros D. Acute Respiratory Events in Connective Tissue Disorders. Respiration 2016; 91:181-201. [PMID: 26938462 DOI: 10.1159/000444535] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Subacute-acute, hyperacute, or even catastrophic and fulminant respiratory events occur in almost all classic connective tissue disorders (CTDs); they may share systemic life-threatening manifestations, may precipitously lead to respiratory failure requiring ventilatory support as well as a combination of specific therapeutic measures, and in most affected patients constitute the devastating end-of-life event. In CTDs, acute respiratory events may be related to any respiratory compartment including the airways, lung parenchyma, alveolar capillaries, lung vessels, pleura, and ventilatory muscles. Acute respiratory events may also precipitate disease-specific extrapulmonary organ involvement such as aspiration pneumonia and lead to digestive tract involvement and heart-related respiratory events. Finally, antirheumatic drug-related acute respiratory toxicity as well as lung infections related to the rheumatic disease and/or to immunosuppression complete the spectrum of acute respiratory events. Overall, in CTDs the lungs significantly contribute to morbidity and mortality, since they constitute a common site of disease involvement; a major site of infections related to the 'mater' disease; a major site of drug-related toxicity, and a common site of treatment-related infectious complications. The extreme spectrum of the abovementioned events, as well as the 'vicious' coexistence of most of the aforementioned manifestations, requires skills, specific diagnostic and therapeutic means, and most of all a multidisciplinary approach of adequately prepared and expert scientists. Avoiding lung disease might represent a major concern for future advancements in the treatment of autoimmune disorders.
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Affiliation(s)
- Spyros A Papiris
- 2nd Department of Pneumonology, x2018;Attikon' University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
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[Recurrent diffuse alveolar hemorrhage in systemic lupus erytematosus treated with rituximab and immunoglobulins]. Med Clin (Barc) 2015; 145:507-8. [PMID: 25858768 DOI: 10.1016/j.medcli.2015.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 02/12/2015] [Indexed: 11/21/2022]
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Abstract
Systemic lupus erythematosus (SLE) is a clinically diverse and potentially life-threatening auto-immune disease that can affect almost any organ system. Although much is still unknown regarding its pathogenesis, B cell abnormalities are thought to be central. A high relapse rate along with the toxicity associated with conventional treatments signify the need for more tailored approaches in this very heterogeneous disease. Both its mechanism targeting B cells and a relatively large number of case series and observational studies have suggested that the B cell-depleting agent rituximab could be a potent SLE drug. However, two randomized controlled trials failed to meet efficacy endpoints. Nevertheless, rituximab has continued to be used as an off-label alternative mainly in patients refractory to conventional immunosuppressive treatment. This article will review the current role of rituximab in SLE.
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Affiliation(s)
- Sara Linder Ekö
- Unit for Clinical Therapy Research, Inflammatory Diseases (ClinTRID), Karolinska Institute, 171 76, Stockholm, Sweden,
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Tse JR, Schwab KE, McMahon M, Simon W. Rituximab: an emerging treatment for recurrent diffuse alveolar hemorrhage in systemic lupus erythematosus. Lupus 2014; 24:756-9. [DOI: 10.1177/0961203314564235] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 11/20/2014] [Indexed: 11/15/2022]
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare manifestation of systemic lupus erythematosus (SLE) and is associated with high mortality rates. Treatment typically consists of aggressive immunosuppression with pulse-dose steroids, cyclophosphamide, and plasma exchange therapy. Mortality rates remain high despite use of multiple medical therapies. We present a case of recurrent DAH in a 52-year-old female with SLE after a deceased donor renal transplant who was successfully treated with rituximab. Our report highlights the pathophysiologic importance of B-cell-mediated immunosuppression in SLE-associated DAH and suggests that rituximab may represent a viable alternative to cyclophosphamide in the treatment of this disease. We also review eight other reported cases of rituximab use in SLE-associated DAH.
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Affiliation(s)
- J R Tse
- Department of Medicine, 1Division of General Internal Medicine
| | - K E Schwab
- Department of Medicine, 1Division of General Internal Medicine
| | - M McMahon
- Division of Rheumatology, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - W Simon
- Department of Medicine, 1Division of General Internal Medicine
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