Diffuse alveolar haemorrage as initial presentation of systemic lupus erythematosus: a case report

Undercover lung damage in pediatrics - a hot spot in morbidity caused by collagenoses

Connective tissue represents the support matrix and the connection between tissues and organs. In its composition, collagen, the major structural protein, is the main component of the skin, bones, tendons and ligaments. Especially at the pediatric age, its damage in the context of pathologies such as systemic lupus erythematosus, scleroderma or dermatomyositis can have a significant negative impact on the development and optimal functioning of the body. The consequences can extend to various structures (e.g., joints, skin, eyes, lungs, heart, kidneys). Of these, we retain and reveal later in our manuscript, mainly the respiratory involvement. Manifested in various forms that can damage the chest wall, pleura, interstitium or vascularization, lung damage in pediatric systemic inflammatory diseases is underdeveloped in the literature compared to that described in adults. Under the threat of severe evolution, sometimes rapidly progressive and leading to death, it is necessary to increase the popularization of information aimed at physiopathological triggering and maintenance mechanisms, diagnostic means, and therapeutic directions among medical specialists. In addition, we emphasize the need for interdisciplinary collaboration, especially between pediatricians, rheumatologists, infectious disease specialists, pulmonologists, and immunologists. Through our narrative review we aimed to bring up to date, in a concise and easy to assimilate, general principles regarding the pulmonary impact of collagenoses using the most recent articles published in international libraries, duplicated by previous articles, of reference for the targeted pathologies.

Exosomes Derived from Human Umbilical Cord Mesenchymal Stem Cells Regulate Macrophage Polarization to Attenuate Systemic Lupus Erythematosus-Associated Diffuse Alveolar Hemorrhage in Mice

Background and Objectives

To investigate the effect and the underlying mechanism of exosomes secreted by human umbilical cord mesenchymal stem cells (hUCMSCs) on diffuse alveolar hemorrhage (DAH) in murine lupus.

Methods and Results

Exosomes were extracted from cultured hUCMSCs by ultracentrifugation. The expressions of exosome markers (Alix, CD63 and TSG101) were measured for identification of hUCMSC-derived exosomes (hUCMSC-exosomes). The alveolar hemorrhage of DAH mice was revealed by H&E staining. The primary alveolar macrophages were isolated from bronchoalveolar lavage fluid (BALF) of DAH mice. The expressions of M1 macrophage markers (iNOS, IL-6, TNF-α and IL-1β) and M2 macrophage markers (Arg1, IL-10, TGF-β and chi3l3) were detected. Flow cytometry measured the ratio of M1/M2 macrophages. ELISA measured the secretion of pro-inflammatory cytokines (IL-6 and TNF-α) and anti-inflammatory cytokines (IL-10 and TGF-β). DAH mice had hemorrhage and small-vessel vasculitis in the lung, with neutrophil and monocyte infiltration observed around the capillary and small artery. Furthermore, increases of IL-6 and TNF-α, and decreases of IL-10 and TGF-β were detected in the BALF of DAH mice. M1 makers were overexpressed in alveolar macrophages of DAH mice while M2 makers were lowly expressed. DAH mice had a higher proportion of M1 macrophages than M2 macrophages. After hUCMSC-exosome or methylprednisolone treatment in DAH mice, the alveolar injuries and inflammatory responses were attenuated, and the proportion of M2 macrophages was increased.

Conclusions

hUCMSC-exosomes attenuate DAH-induced inflammatory responses and alveolar hemorrhage by regulating macrophage polarization.

Traumatic lingual haematoma: Another unusual cause of upper airway obstruction in systemic lupus erythematosus

Lingual hematoma (LH) is an uncommon and potentially life-threatening condition due to its tendency to cause upper airway obstruction. It usually occurs as a result of trauma (motor vehicle accidents, grand mal seizures or traumatic tracheal intubations) and rarely spontaneously in cases of patients with inherited or acquired coagulopathies, high blood pressure, hematological disorders, or vascular malformations.

Herein, we report the first case, to our knowledge, of a traumatic massive lingual hematoma in a patient with Systemic lupus erythematosus (SLE) secondary to tongue biting after neurological deterioration, hypertensive crisis and multiple tonic clonic seizures during hemodialysis for chronic renal failure.

Predictors of Mortality in Pulmonary Haemorrhage during SLE: A Single Centre Study Over Eleven Years

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.

Acute diffuse alveolar haemorrhage accompanied by gastrointestinal bleeding in a patient with serious systemic lupus erythematosus: A case report

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects many organs, but multisystem dysfunction is rare. Here, we report a case of a 29-year-old woman who was initially diagnosed with SLE complications including lupus nephritis, lupus encephalopathy, renal hypertension, thrombocytopenia, anaemia and hyperkalaemia. She recovered following treatment with high dose methylprednisolone, intravenous immunoglobulin (IVIG) and continuous renal replacement therapy (CRRT). However, a few days after hospital discharge, she developed gastrointestinal bleeding. Although intensive treatment was administered, the patient deteriorated rapidly and had a progressive decline in oxygen saturation followed by diffuse alveolar haemorrhage and acute left heart failure. Inotropic therapy, mechanical ventilation, blood transfusion, CRRT, antibiotics, intravenous glucocorticoids and other support therapies were initiated and gradually the patient's vital signs stabilized and haemoptysis subsided. This case report emphasises that complications of SLE can occur at any stage of the disease, especially in patients with active SLE. Therefore, it is important for clinicians to be aware of the rare presentations of SLE and its complex management. For multisystem dysfunction, early intensive treatment with high dose corticosteroids and cyclophosphamide is advocated.