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Poli S, Sciorio F, Piacentini G, Pietrobelli A, Pecoraro L, Pieropan S. Acute Respiratory Failure in Autoimmune Rheumatic Diseases: A Review. J Clin Med 2024; 13:3008. [PMID: 38792549 PMCID: PMC11122618 DOI: 10.3390/jcm13103008] [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: 04/01/2024] [Revised: 05/08/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024] Open
Abstract
This review examines respiratory complications in autoimmune rheumatic diseases within intensive care units (ICUs). The respiratory system, primarily affected in diseases like rheumatoid arthritis, systemic lupus erythematosus, and scleroderma, often leads to respiratory failure. Common manifestations include alveolar hemorrhage, interstitial fibrosis, and acute respiratory distress syndrome. Early recognition and treatment of non-malignant conditions are crucial to prevent rapid disease progression, with ICU mortality rates ranging from 30% to 60%. Delayed immunosuppressive or antimicrobial therapy may result in organ system failure. Collaboration with rheumatic specialists is vital for accurate diagnosis and immediate intervention. Mortality rates for rheumatic diseases in the ICU surpass those of other conditions, underscoring the need for specialized care and proactive management. The review emphasizes comprehensive assessments, distinguishing disease-related complications from underlying issues, and the importance of vigilant monitoring to enhance patient outcomes.
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Affiliation(s)
| | | | | | | | - Luca Pecoraro
- Pediatric Clinic, Department of Surgical Sciences, Dentistry, Pediatrics and Gynecology, University of Verona, 37126 Verona, Italy
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Dumas G, Arabi YM, Bartz R, Ranzani O, Scheibe F, Darmon M, Helms J. Diagnosis and management of autoimmune diseases in the ICU. Intensive Care Med 2024; 50:17-35. [PMID: 38112769 DOI: 10.1007/s00134-023-07266-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023]
Abstract
Autoimmune diseases encompass a broad spectrum of disorders characterized by disturbed immunoregulation leading to the development of specific autoantibodies, resulting in inflammation and multiple organ involvement. A distinction should be made between connective tissue diseases (mainly systemic lupus erythematosus, systemic scleroderma, inflammatory muscle diseases, and rheumatoid arthritis) and vasculitides (mainly small-vessel vasculitis such as antineutrophil cytoplasmic antibody-associated vasculitis and immune-complex mediated vasculitis). Admission of patients with autoimmune diseases to the intensive care unit (ICU) is often triggered by disease flare-ups, infections, and organ failure and is associated with high mortality rates. Management of these patients is complex, including prompt disease identification, immunosuppressive treatment initiation, and life-sustaining therapies, and requires multi-disciplinary involvement. Data about autoimmune diseases in the ICU are limited and there is a need for multicenter, international collaboration to improve patients' diagnosis, management, and outcomes. The objective of this narrative review is to summarize the epidemiology, clinical features, and selected management of severe systemic autoimmune diseases.
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Affiliation(s)
- Guillaume Dumas
- Medical Intensive Care Unit, Service de Médecine Intensive-Réanimation, CHU Grenoble-Alpes, Université Grenoble-Alpes, INSERM, U1042-HP2, Grenoble, France.
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences Riyadh, Riyadh, Kingdom of Saudi Arabia
| | - Raquel Bartz
- Department of Anesthesia, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Otavio Ranzani
- Barcelona Institute for Global Health, ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Pulmonary Division, Faculdade de Medicina, Heart Institute, InCor, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Franziska Scheibe
- Department of Neurology and Experimental Neurology, Charité- Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Michaël Darmon
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA Team, and Clinical EpidemiologyUMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Université Paris Cité, Paris, France
| | - Julie Helms
- Faculté de Médecine, Service de Médecine Intensive-Réanimation, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1 Place de L'Hôpital, Strasbourg, France
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Gibelin A, Dumas G, Valade S, de Chambrun MP, Bagate F, Neuville M, Schneider F, Baboi L, Groh M, Raphalen JH, Chiche JD, De Prost N, Luyt CE, Guérin C, Maury E, de Montmollin E, Hertig A, Parrot A, Clere-Jehl R, Fartoukh M. Causes of acute respiratory failure in patients with small-vessel vasculitis admitted to intensive care units: a multicenter retrospective study. Ann Intensive Care 2021; 11:158. [PMID: 34817718 PMCID: PMC8613321 DOI: 10.1186/s13613-021-00946-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 11/02/2021] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Acute respiratory failure (ARF) in patients admitted to the intensive care unit (ICU) with known or de novo small-vessel vasculitis (Svv) may be secondary to the underlying immune disease or to other causes. Early identification of the cause of ARF is essential to initiate the most appropriate treatment in a timely fashion. METHODS A retrospective multicenter study in 10 French ICUs from January 2007 to January 2018 to assess the clinical presentation, main causes and outcome of ARF associated with Svv, and to identify variables associated with non-immune etiology of ARF in patients with known Svv. RESULTS During the study period, 121 patients [62 (50-75) years; 62% male; median SAPSII and SOFA scores 39 (27-52) and 6 (4-8), respectively] were analyzed. An immune cause was identified in 67 (55%), and a non-immune cause in 54 (45%) patients. ARF was associated with several causes in 43% (n = 52) of cases. The main immune cause was diffuse alveolar hemorrhage (DAH) (n = 47, 39%), whereas the main non-immune cause was pulmonary infection (n = 35, 29%). The crude 90-day and 1-year mortality were higher in patients with non-immune ARF, as compared with their counterparts (32% and 38% vs. 15% and 20%, respectively; both p = 0.03), but was marginally significantly higher after adjusted analysis in a Cox model (p = 0.053). Among patients with a known Svv (n = 70), immunosuppression [OR 9.41 (1.52-58.3); p = 0.016], and a low vasculitis activity score [0.84 (0.77-0.93)] were independently associated with a non-immune cause, after adjustment for the time from disease onset to ARF, time from respiratory symptoms to ICU admission, and severe renal failure. CONCLUSIONS An extensive diagnosis workup is mandatory in ARF revealing or complicating Svv. Non-immune causes are involved in 43% of cases, and their short and mid-term prognosis may be poorer than those of immune ARF. Readily identified predictive factors of a non-immune cause could help avoiding unnecessary immunosuppressive therapies.
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Affiliation(s)
- Aude Gibelin
- Service de Médecine Intensive Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, 4 rue de la chine, 75020, Paris, France.
| | - Guillaume Dumas
- Service de Médecine Intensive Réanimation, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France.,Service de Médecine Intensive Réanimation, Faculté de Médecine Sorbonne Université, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sandrine Valade
- Service de Médecine Intensive Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive Réanimation, Faculté de Médecine Sorbonne Université, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - François Bagate
- Service de Médecine Intensive Réanimation, Faculté de Santé de Créteil, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP) and Groupe de Recherche Clinique CARMAS, Université Paris Est Créteil, Cedex 94010, Créteil, France
| | - Mathilde Neuville
- Service de Médecine Intensive et Réanimation Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, IAME, UMR 1137, Paris, France
| | - Francis Schneider
- Service de Médecine Intensive Réanimation, Hôpital Hautepierre, Strasbourg, France
| | - Loredana Baboi
- Service de Médecine Intensive-Réanimation Groupement Hospitalier Centre, Hôpital Edouard Herriot, Lyon, France
| | - Matthieu Groh
- Service de Médecine Interne, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Herlé Raphalen
- Service de Réanimation Adultes, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Daniel Chiche
- Service de Médecine Intensive Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nicolas De Prost
- Service de Médecine Intensive Réanimation, Faculté de Santé de Créteil, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP) and Groupe de Recherche Clinique CARMAS, Université Paris Est Créteil, Cedex 94010, Créteil, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Faculté de Médecine Sorbonne Université, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Claude Guérin
- Service de Médecine Intensive-Réanimation Groupement Hospitalier Centre, Hôpital Edouard Herriot, Lyon, France
| | - Eric Maury
- Service de Médecine Intensive Réanimation, Faculté de Médecine Sorbonne Université, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Etienne de Montmollin
- Service de Médecine Intensive et Réanimation Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, IAME, UMR 1137, Paris, France
| | - Alexandre Hertig
- Service de Néphrologie, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France
| | - Antoine Parrot
- Service de Médecine Intensive Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, 4 rue de la chine, 75020, Paris, France
| | - Raphaël Clere-Jehl
- Service de Médecine Intensive Réanimation, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Muriel Fartoukh
- Service de Médecine Intensive Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, 4 rue de la chine, 75020, Paris, France
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Zhang Y, Guo J, Zhang P, Zhang L, Duan X, Shi X, Guo N, Liu S. Predictors of Mortality in Critically Ill Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Front Med (Lausanne) 2021; 8:762004. [PMID: 34760903 PMCID: PMC8573203 DOI: 10.3389/fmed.2021.762004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/28/2021] [Indexed: 01/29/2023] Open
Abstract
Background: Patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV) may require intensive care unit (ICU) admission due to different reasons, and the in-ICU mortality is high among AAV patients. The aim of this study was to explore the clinical features and risk factors of mortality of patients with AAV in the ICU. Methods: A retrospective study was conducted based on 83 AAV patients admitted to the ICU in a tertiary medical institution in China. Data on clinical characteristics, laboratory tests, treatment in ICU and outcomes were collected. The data were analyzed using univariate and multivariate logistic regression analysis to explore the variables that were independently related to mortality. Kaplan–Meier method was used to assess the long-term survival. Results: Among the 83 patients, 41 (49.4%) were female. The mean age of patients was 66 ± 13 years. Forty-four patients deceased, with the in-ICU mortality of 53%. The most common cause for ICU admission was active vasculitis (40/83, 48.2%). The main cause of death was infection (27/44, 61.4%) followed by active vasculitis (15/44, 34.1%). A multivariate analysis revealed that the Acute Physiology and Chronic Health Evaluation II (APACHE II) at ICU admission (OR = 1.333, 95% CI: 1.031–1.722) and respiratory failure (OR = 620.452, 95% CI: 11.495–33490.306) were independent risk factors of in-ICU death. However, hemoglobin (OR = 0.919, 95% CI: 0.849–0.995) was an independent protective factor. The nomogram established in this study was practical in predicting the risk of in-ICU mortality for AAV patients. Moreover, for 39 patients survived to the ICU stay, the cumulative survival rates at 0.5, 1, and 5 years were 58.3%, 54.2%, and 33.9%, respectively, and the median survival time was 14 months. Conclusion: In our study, active vasculitis was the most frequent reason for ICU admission, and the main cause of death was infection. APACHE II and respiratory failure were independent risk factors while hemoglobin was an independent protective factor of in-ICU mortality for AAV patients admitted to the ICU. The risk prediction model developed in this study may be a useful tool for clinicians in early recognition of high-risk patients and applying appropriate management.
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Affiliation(s)
- Yuqi Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jinyan Guo
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Panpan Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lei Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaoguang Duan
- Department of Intensive Care Unit, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaofei Shi
- Department of Rheumatology, the First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, China
| | - Nailiang Guo
- Department of Rheumatology and Immunology, Xinyang Central Hospital, Xinyang, China
| | - Shengyun Liu
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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van Gemert JP, van den Berk IAH, Nossent EJ, Heunks LMA, Jonkers RE, Vlaar AP, Bonta PI. Cyclophosphamide for interstitial lung disease-associated acute respiratory failure: mortality, clinical response and radiological characteristics. BMC Pulm Med 2021; 21:249. [PMID: 34320981 PMCID: PMC8316896 DOI: 10.1186/s12890-021-01615-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 07/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Treatment for interstitial lung disease (ILD) patients with acute respiratory failure (ARF) is challenging, and literature to guide such treatment is scarce. The reported in-hospital mortality rates of ILD patients with ARF are high (62–66%). Cyclophosphamide is considered a second-line treatment in steroid-refractory ILD-associated ARF. The first aim of this study was to evaluate the in-hospital mortality in patients with ILD-associated ARF treated with cyclophosphamide. The second aim was to compare computed tomographic (CT) patterns and physiological and ventilator parameters between survivors and non-survivors. Methods Retrospective analysis of patients with ILD-associated ARF treated with cyclophosphamide between February 2016 and October 2017. Patients were categorized into three subgroups: connective tissue disease (CTD)-associated ILD, other ILD or vasculitis. In-hospital mortality was evaluated in the whole cohort and in these subgroups. Clinical response was determined using physiological and ventilator parameters: Sequential Organ Failure Assessment Score (SOFA), PaO2/FiO2 (P/F) ratio and dynamic compliance (Cdyn) before and after cyclophosphamide treatment. The following CT features were quantified: ground-glass opacification (GGO) proportion, reticulation proportion, overall extent of parenchymal disease and fibrosis coarseness score. Results Fifteen patients were included. The overall in-hospital mortality rate was 40%. In-hospital mortality rates for CTD-associated ILD, other ILD and vasculitis were 20, 57, and 33%, respectively. The GGO proportion (71% vs 45%) was higher in non-survivors. There were no significant differences in the SOFA score, P/F ratio or Cdyn between survivors and non-survivors. However, in survivors the P/F ratio increased from 129 to 220 mmHg and Cdyn from 75 to 92 mL/cmH2O 3 days after cyclophosphamide treatment. In non-survivors the P/F ratio hardly changed (113–114 mmHg) and Cdyn even decreased (27–20 mL/cmH2O). Conclusion In this study, we found a mortality rate of 40% in patients treated with cyclophosphamide for ILD-associated ARF. Connective tissue disease-associated ILD and vasculitis were associated with a lower risk of death. In non-survivors, the CT GGO proportion was significantly higher. The P/F ratio and Cdyn in survivors increased after 3 days of cyclophosphamide treatment. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01615-2.
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Affiliation(s)
- Johanna P van Gemert
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Location AMC, University of Amsterdam, Amsterdam, The Netherlands. .,Department of Pulmonary Diseases, University Medical Center Groningen (UMCG), Hanzeplein 1, HP BB72, 9700 RB, Groningen, The Netherlands.
| | - Inge A H van den Berk
- Department of Radiology, Amsterdam University Medical Center, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Esther J Nossent
- Department of Respiratory Medicine, Amsterdam University Medical Center, Location VUMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Location VUMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Rene E Jonkers
- Department of Respiratory Medicine, Amsterdam University Medical Center, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexander P Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter I Bonta
- Department of Respiratory Medicine, Amsterdam University Medical Center, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
Ophthalmic disease encountered in the intensive care unit (ICU) has a wide spectrum of prevalence and severity. Prolonged exposure of the cornea is common and preventable. Trauma, glaucoma, infection, vascular disease, and burns are among the potential causes of vision loss. Patients are predisposed to ocular complications by the ICU environment and critical illness itself. Critically ill patients require prioritization of life-sustaining interventions, and less emphasis is placed on ophthalmic disease, leading to missed opportunities for vision-saving intervention. It is therefore imperative for intensivists, nurses, and other providers to have an increased awareness and understanding of the broad range of ocular conditions potentially seen in the ICU.
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Zhou D, Zhang P, Zhang Y, Zhang Y, Zhang X, Li J, Zhou Z, Zhu N. Main tract stenosis complicated by granulomatous with polyangiitis: A case report. Exp Ther Med 2020; 19:3332-3336. [PMID: 32266030 PMCID: PMC7132230 DOI: 10.3892/etm.2020.8603] [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] [Received: 07/27/2019] [Accepted: 02/07/2020] [Indexed: 11/06/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a rheumatic auto-immune disease involved in vasculitis. It is rarely reported that anti-neutrophil cytoplasmic antibodies (ANCAs) associated with GPA would cause main tract stenosis. The current report documents a 54-year-old woman, with a history of severe cough, presented with wheezing and shortness of breath. Although she was treated with cephalosporin antibiotics for half a month, the symptoms were not alleviated. Accordingly, laboratory testing, radiology and pathology was performed at the Department of Respiratory and Critical Care Medicine, Huashan Hospital. Blood samples were tested negative for ANCAs. Chest CT revealed stenosis of the main trachea and uneven thickening of the tracheal wall. Nasal sinuses CT scanning indicated thickening of the nasal mucosa. Pathological analysis demonstrated chronic granulomatous inflammation with focal lesions. According to the classification criteria of ACR/EULAR provisional 2017, the patient was diagnosed with the ANCAs-negative GPA. Following treatment with oral prednisone only for 6 months, obstruction of main tract was significantly improved. This case study is of interest for the promotion a potentially novel therapeutic intervention for GPA associated with the absence ANCA of in clinic.
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Affiliation(s)
- Daibing Zhou
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Peng Zhang
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Yuanyuan Zhang
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Youzhi Zhang
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Xiujuan Zhang
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Jing Li
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Zhongwen Zhou
- Department of Pathology, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
| | - Ning Zhu
- Department of Respiratory and Critical Care Medicine, Huashan Hospital, Fudan University, Jing'an, Shanghai 200040, P.R. China
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Recommendations for managing the manifestations of severe and life-threatening mixed cryoglobulinemia syndrome. Autoimmun Rev 2019; 18:778-785. [PMID: 31181326 DOI: 10.1016/j.autrev.2019.06.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 02/22/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Some of the manifestations of mixed cryoglobulinemia syndrome (MCS) can be severe or life-threatening, and should be rapidly contained but, as the therapeutic approaches to such conditions are largely based on anecdotal data, a consensus conference was organised by the Italian Group for the Study of Cryoglobulinemia (GISC) with the aim of providing a set of recommendations based on an in-depth survey of the available data and expert opinion. METHODS The consensus panel, which included specialists working in different medical fields involved in the management of MCS patients, was first asked to divide the manifestations of MCS into severe or life-threatening conditions on the basis of their own experience, after which a complete literature review was carried out in accordance with the Cochrane guidelines for systematic reviews. RESULTS Therapeutic plasma exchange (TPE) was considered the elective first-line treatment in the case of life-threatening manifestations of MCS (LT-MCS) and patients with severe clinical symptoms (S-MCS) who fail to respond to (or who are ineligible for) other treatments. The data supporting the combined use of cyclophosphamide and TPE were considered limited and inconclusive. High-dose pulsed glucocorticoid (GCS) therapy can be considered the first-line treatment of severe MCS, generally in association with TPE. Rituximab (RTX)-based treatments should be considered in patients with skin ulcers, peripheral neuropathy or glomerulonephritis, and in patients with persistent LT-MCS after TPE. In patients with hepatitis C virus-related MCS with S-MCS, viral eradication should be attempted as soon as a patient's condition allows the use of direct-acting antivirals.
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Kimmoun A, Levy B. Vascularites à anticorps anticytoplasme des polynucléaires neutrophiles et réanimation : quel pronostic en 2018 ? MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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10
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Kimmoun A, Baux E, Das V, Terzi N, Talec P, Asfar P, Ehrmann S, Geri G, Grange S, Anguel N, Demoule A, Moreau AS, Azoulay E, Quenot JP, Boisramé-Helms J, Louis G, Sonneville R, Girerd N, Ducrocq N, Agrinier N, Wahl D, Puéchal X, Levy B. Outcomes of patients admitted to intensive care units for acute manifestation of small-vessel vasculitis: a multicenter, retrospective study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:27. [PMID: 26812945 PMCID: PMC4729170 DOI: 10.1186/s13054-016-1189-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/14/2016] [Indexed: 11/25/2022]
Abstract
Background The outcomes of patients admitted to the intensive care unit (ICU) for acute manifestation of small-vessel vasculitis are poorly reported. The aim of the present study was to determine the mortality rate and prognostic factors of patients admitted to the ICU for acute small-vessel vasculitis. Methods This retrospective, multicenter study was conducted from January 2001 to December 2014 in 20 ICUs in France. Patients were identified from computerized registers of each hospital using the International Classification of Diseases, Ninth Revision (ICD-9). Inclusion criteria were (1) known or highly suspected granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis (respectively, ICD-9 codes M31.3, M30.1, and M31.7), or anti–glomerular basement membrane antibody disease (ICD-9 codes N08.5X-005 or M31.0+); (2) admission to the ICU for the management of an acute manifestation of vasculitis; and (3) administration of a cyclophosphamide pulse in the ICU or within 48 h before admission to the ICU. The primary endpoint was assessment of mortality rate 90 days after admission to the ICU. Results Eighty-two patients at 20 centers were included, 94 % of whom had a recent (<6 months) diagnosis of small-vessel vasculitis. Forty-four patients (54 %) had granulomatosis with polyangiitis. The main reasons for admission were respiratory failure (34 %) and pulmonary-renal syndrome (33 %). Mechanical ventilation was required in 51 % of patients, catecholamines in 31 %, and renal replacement therapy in 71 %. Overall mortality at 90 days was 18 % and the mortality in ICU was 16 %. The main causes of death in the ICU were disease flare in 69 % and infection in 31 %. In univariable analysis, relevant factors associated with death in nonsurvivors compared with survivors were Simplified Acute Physiology Score II (median [interquartile range] 51 [38–82] vs. 36 [27–42], p = 0.005), age (67 years [62–74] vs. 58 years [40–68], p < 0.003), Sequential Organ Failure Assessment score on the day of cyclophosphamide administration (11 [6–12] vs. 6 [3–7], p = 0.0004), and delayed administration of cyclophosphamide (5 days [3–14] vs. 2 days [1–5], p = 0.0053). Conclusions Patients admitted to the ICU for management of acute small-vessel vasculitis benefit from early, aggressive intensive care treatment, associated with an 18 % death rate at 90 days. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1189-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antoine Kimmoun
- Brabois Medical Intensive Care Unit, Nancy University Hospital, Vandoeuvre-les-Nancy, Nancy, 54000, France.,INSERM U1116, Vandoeuvre-les-Nancy, Nancy, France
| | - Elisabeth Baux
- Brabois Medical Intensive Care Unit, Nancy University Hospital, Vandoeuvre-les-Nancy, Nancy, 54000, France.,INSERM U1116, Vandoeuvre-les-Nancy, Nancy, France
| | - Vincent Das
- Medical-Surgical Intensive Care Unit, Andre Gregoire District Hospital Center, Montreuil, F-93105, France
| | - Nicolas Terzi
- Medical Intensive Care Unit, Caen University Hospital, Avenue de la Côte de Nacre, 14000, Caen, France
| | - Patrice Talec
- Medical Intensive Care Unit, Angers University Hospital, Angers, F-49933, France
| | - Pierre Asfar
- Medical Intensive Care Unit, Angers University Hospital, Angers, F-49933, France
| | - Stephan Ehrmann
- Medical Intensive Care Unit, Bretonneau University Hospital, Tours, F-37044, France
| | - Guillaume Geri
- Medical Intensive Care Unit, Cochin University Hospital, Paris, F-75014, France
| | - Steven Grange
- Medical Intensive Care Unit, Rouen University Hospital, Rouen, 76031, France
| | - Nadia Anguel
- Medical Intensive Care Unit, Kremlin-Bicêtre University Hospital, Paris, F-94275, France
| | - Alexandre Demoule
- Medical Intensive Care Unit and Respiratory Division, Pitié-Salpêtrière University Hospital, Paris, 75013, France
| | - Anne Sophie Moreau
- Medical-Surgical Intensive Care Unit, Lille University Hospital, Lille, F-59000, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis University Hospital, Paris, 75010, France
| | - Jean-Pierre Quenot
- Medical Intensive Care Unit, Dijon University Hospital, Dijon, F-21079, France
| | - Julie Boisramé-Helms
- Medical Intensive Care Unit, NHC University Hospital, Strasbourg, F-67091, France
| | - Guillaume Louis
- Medical Intensive Care Unit, Mercy Regional Hospital, Ars-Laquenexy, 57530, France
| | - Romain Sonneville
- Medical Intensive Care Unit, Bichat - Claude-Bernard University Hospital, Paris, 75018, France
| | - Nicolas Girerd
- INSERM CIC1433, Nancy University Hospital, Nancy, 54000, France
| | - Nicolas Ducrocq
- Brabois Medical Intensive Care Unit, Nancy University Hospital, Vandoeuvre-les-Nancy, Nancy, 54000, France.,INSERM U1116, Vandoeuvre-les-Nancy, Nancy, France
| | - Nelly Agrinier
- INSERM CIC-EC, CIE6, Nancy University Hospital, Nancy, 54000, France
| | - Denis Wahl
- Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy University Hospital, Vandoeuvre-les Nancy, Nancy, 54511, France
| | - Xavier Puéchal
- National Referral Center for Necrotizing Vasculitides and Systemic Sclerosis, Cochin Hospital, University Paris Descartes, Paris, F-75014, France
| | - Bruno Levy
- Brabois Medical Intensive Care Unit, Nancy University Hospital, Vandoeuvre-les-Nancy, Nancy, 54000, France. .,INSERM U1116, Vandoeuvre-les-Nancy, Nancy, France.
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11
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Sung IY, Kim YM, Cho YC, Son JH. Role of gingival manifestation in diagnosis of granulomatosis with polyangiitis (Wegener's granulomatosis). J Periodontal Implant Sci 2015; 45:247-51. [PMID: 26734495 PMCID: PMC4698952 DOI: 10.5051/jpis.2015.45.6.247] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/27/2015] [Indexed: 11/22/2022] Open
Abstract
Purpose This report describes a case of granulomatosis with polyangiitis (GPA) in which the gingival manifestation was crucial in both making an early diagnosis and possibly in deciding the approach to treatment. Methods A 57-year-old sailor presented to the Department of Dentistry at Ulsan University Hospital complaining of gingival swelling since approximately 2 months. He had orofacial granulomatous lesions and the specific gingival manifestation of strawberry gingivitis. Results The diagnosis of GPA was made on the basis of clinical symptoms and signs, and confirmed by the presence of the anti-neutrophil cytoplasmic antibody and a positive biopsy. The patient was admitted to the hospital and subsequently placed on a disease-modifying therapy regimen that included methotrexate and prednisone. Conclusions Identification of the gingival manifestation of the disease permitted an early diagnosis and prompt therapy in a disease in which time is a crucial factor. Because of its rapid progression and potentially fatal outcome, an early diagnosis of GPA is important. Therefore, dentists should be aware of the oral signs and symptoms of such systemic diseases.
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Affiliation(s)
- Iel-Yong Sung
- Department of Dentistry, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Young-Min Kim
- Department of Pathology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Yeong-Cheol Cho
- Department of Dentistry, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jang-Ho Son
- Department of Dentistry, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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12
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Rajagopala S, Sagar BKP, Thabah MM, Srinivas BH, Venkateswaran R, Parameswaran S. Pulmonary-renal syndromes: Experience from an Indian Intensive Care Unit. Indian J Crit Care Med 2015. [PMID: 26195857 PMCID: PMC4478672 DOI: 10.4103/0972-5229.158261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The etiology of patients presenting with pulmonary-renal syndrome (PRS) to Intensive Care Units (ICUs) in India is not previously reported. AIMS The aim was to describe the prevalence, etiology, clinical manifestations, and outcomes of PRS in an Indian ICU and identify variables that differentiate immunologic causes of PRS from tropical syndromes presenting with PRS. MATERIALS AND METHODS We conducted a prospective observational study of all patients presenting with PRS over 1-year. Clinical characteristics of patients with "definite PRS" were compared with those with "PRS mimics". RESULTS We saw 27 patients with "provisional PRS" over the said duration; this included 13 patients with "definite PRS" and 14 with "PRS mimics". The clinical symptoms were similar, but patients with PRS were younger and presented with longer symptom duration. Ninety-two percent of the PRS cohort required mechanical ventilation, 77% required vasopressors and 61.5% required dialysis within 48 h of ICU admission. The etiologic diagnosis of PRS was made after ICU admission in 61.5%. Systemic lupus erythrematosus (54%) was the most common diagnosis. A combination of biopsy and serology was needed in the majority (69%, 9/13). Pulse methylprednisolone (92%) and cyclophosphamide (61.5%) was the most common protocol employed. Patients with PRS had more alveolar hemorrhage, hypoxemia and higher mortality (69%) when compared to "PRS mimics". CONCLUSION The spectrum of PRS is different in the tropics and tropical syndromes presenting with PRS are not uncommon. Multicentric studies are needed to further characterize the burden, etiology, treatment protocols, and outcomes of PRS in India.
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Affiliation(s)
- Srinivas Rajagopala
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, India
| | - Baburao Kanthamani Pramod Sagar
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, India
| | - Molly Mary Thabah
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, India
| | - B H Srinivas
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, India
| | - Ramanathan Venkateswaran
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, India
| | - Sreejith Parameswaran
- Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, India
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13
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Renal disease presenting as acute kidney injury: the diagnostic conundrum on the intensive care unit. Curr Opin Crit Care 2015; 20:606-12. [PMID: 25340380 DOI: 10.1097/mcc.0000000000000155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) is commonplace in most ICUs. In many cases the cause is believed to be multifactorial with sepsis being a major component. However, occasionally intrinsic renal disease will present to the ICU and as such critical care practitioners should be aware of this possibility and the ways in which such conditions may present. RECENT FINDINGS Although a relatively rare occurrence the treatment for patients with intrinsic renal disease, particularly those who present as part of a vasculitic process, differs considerably from usual organ support employed on intensive care. Recent studies indicate that the outlook for these patients is poor particularly when the diagnosis is delayed. The use of serological investigations as well as other diagnostic techniques are discussed. SUMMARY Not all AKI as described by changes in creatinine and urine output which presents or develops on the ICU is the same. AKI is a syndrome which encompasses many conditions and as such is nondiagnostic. Clinicians, when faced with AKI should satisfy themselves as to the likely cause of the AKI.
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Befort P, Corne P, Filleron T, Jung B, Bengler C, Jonquet O, Klouche K. Prognosis and ICU outcome of systemic vasculitis. BMC Anesthesiol 2013; 13:27. [PMID: 24083831 PMCID: PMC4016298 DOI: 10.1186/1471-2253-13-27] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 09/24/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systemic vasculitis may cause life threatening complications requiring admission to an intensive care unit (ICU). The aim of this study was to evaluate outcomes of systemic vasculitis patients admitted to the ICU and to identify prognosis factors. METHODS During a ten-year period, records of 31 adult patients with systemic vasculitis admitted to ICUs (median age: 63 y.o, sex ratio M/F: 21/10, SAPS II: 40) were reviewed including clinical and biological parameters, use of mechanical ventilation, catecholamine or/and dialysis support. Mortality was assessed and data were analyzed to identify predictive factors of outcome. RESULTS Causes of ICU admissions were active manifestation of vasculitis (n = 19), septic shock (n = 8) and miscellaneous (n = 4). Sixteen patients (52%) died in ICU. By univariate analysis, mortality was associated with higher SOFA (p = 0.006) and SAPS II (p = 0.004) scores. The need for a catecholamine support or/and a renal replacement therapy, and the occurrence of an ARDS significantly worsen the prognosis. By multivariate analysis, only SAPS II (Odd ratio: 1.16, 95% CI [1.01; 1.33]) and BVAS scores (Odd ratio: 1.16, 95% CI = [1.01; 1.34]) were predictive of mortality. CONCLUSION The mortality rate of severe vasculitis requiring an admission to ICU was high. High levels of SAPS II and BVAS scores at admission were predictive of mortality.
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Affiliation(s)
| | | | | | | | | | | | - Kada Klouche
- Department of Intensive Care Unit, Lapeyronie University Hospital, 191 Avenue du Doyen G, Giraud, Montpellier 34090, France.
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15
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Abstract
Some skin conditions may require treatment in intensive care units. The early diagnosis of life-threatening dermatoses is a considerable challenge. We review skin diseases which may require intensive care. In addition to Stevens-Johnson syndrome and toxic epidermal necrolysis, representing adverse skin reactions, we discuss staphylococcal scalded skin syndrome and necrotizing fasciitis as infection-associated dermatoses, as well as angioedema. We focus on the course of disease describing clinical presentations, diagnostics and therapeutic strategies with respect to critical medical conditions.
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Affiliation(s)
- C Marks
- Abt. für Hämatologie/Onkologie, Medizinische Universitätsklinik Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland.
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Almouhawis HA, Leao JC, Fedele S, Porter SR. Wegener's granulomatosis: a review of clinical features and an update in diagnosis and treatment. J Oral Pathol Med 2013; 42:507-16. [PMID: 23301777 DOI: 10.1111/jop.12030] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2012] [Indexed: 01/31/2023]
Abstract
Wegener's granulomatosis (WG) is an idiopathic, systemic inflammatory disease characterized by necrotizing granulomatous inflammation and pauci-immune small-vessel vasculitis of upper and lower respiratory tract and kidneys. The condition affects both genders equally, although some inconsistent gender differences have been observed. The aetiology of WG remains unknown although a number of exogenous factors have been suggested to be of aetiological relevance. Most clinical characteristics of this disease are non-specific, making clinical diagnosis challenging. Histopathological examination of lesional and peritoneal tissue is not pathognomonic, but is an essential investigation to confirm the presence of disease and exclude other disorders. At present, despite the increasingly wide range of potential therapies, cyclophosphamide plus corticosteroids remain the most recognized and effective means of inducing and sustaining remission of WG.
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Affiliation(s)
- Hanan A Almouhawis
- Oral Medicine unit, Department of Maxillofacial Medicine and Surgery, UCL Eastman Dental Institute, London, UK
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17
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Autoimmune diseases in the intensive care unit. An update. Autoimmun Rev 2013; 12:380-95. [DOI: 10.1016/j.autrev.2012.06.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 06/12/2012] [Indexed: 12/18/2022]
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Cardenas-Garcia J, Farmakiotis D, Baldovino BP, Kim P. Wegener's granulomatosis in a middle-aged woman presenting with dyspnea, rash, hemoptysis and recurrent eye complaints: a case report. J Med Case Rep 2012; 6:335. [PMID: 23034218 PMCID: PMC3492078 DOI: 10.1186/1752-1947-6-335] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 02/27/2012] [Indexed: 11/10/2022] Open
Abstract
Introduction Wegener’s granulomatosis presenting as diffuse alveolar hemorrhage is uncommon. However, the recognition of multisystem disease involving joints, kidney, eye and lung is critical for diagnosing Wegener's vasculitis. This is not the first report of this kind in the literature. Case presentation A 51-year-old Croatian woman presented to our Emergency Department with a history of progressively worsening productive cough and shortness of breath, epistaxis and two episodes of hemoptysis. She developed respiratory failure due to diffuse alveolar hemorrhage, which was successfully treated with high-dose steroids, cyclophosphamide and plasmapheresis. Her clinical course was complicated with methicillin-resistant Staphyloccocus aureus pneumonia, which has been associated with Wegener’s granulomatosis flares. Conclusion The recognition of multisystem disease is critical for diagnosing Wegener's vasculitis. Diffuse alveolar hemorrhage can be a fulminant manifestation of Wegener’s granulomatosis, in which case immediate and aggressive treatment with pulse steroids, high-dose cyclophosphamide and plasma exchange can be life-saving.
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Affiliation(s)
- Jose Cardenas-Garcia
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Suite 3N1 1400 Pelham Pkwy S,, Bronx, NY, 10461, USA.
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Zaidan M, Mariotte E, Galicier L, Arnulf B, Meignin V, Vérine J, Mahr A, Azoulay É. Vasculitic emergencies in the intensive care unit: a special focus on cryoglobulinemic vasculitis. Ann Intensive Care 2012; 2:31. [PMID: 22812447 PMCID: PMC3488028 DOI: 10.1186/2110-5820-2-31] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 06/24/2012] [Indexed: 12/25/2022] Open
Abstract
Vasculitis is characterized by the infiltration of vessel walls by inflammatory leukocytes with reactive damage and subsequent loss of vessel integrity. The clinical course of systemic vasculitis may be punctuated by acute life-threatening manifestations that require intensive care unit (ICU) admission. Furthermore, the diagnosis may be established in the ICU after admission for a severe inaugural symptom, mostly acute respiratory failure. Among the systemic vasculitides, cryoglobulinemic vasculitis (CV) has been rarely studied in an ICU setting. Severe CV-related complications may involve the kidneys, lungs, heart, gut, and/or central nervous system. The diagnosis of CV in the ICU may be delayed or completely unrecognized. A high level of suspicion is critical to obtain a timely and accurate diagnosis and to initiate appropriate treatment. We describe severe acute manifestations of CV based on six selected patients admitted to our ICU. That all six patients survived suggests the benefit of prompt ICU admission of patients with severe CV.
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Affiliation(s)
- Mohamad Zaidan
- Department of Medical Intensive Care Unit, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Eric Mariotte
- Department of Medical Intensive Care Unit, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Lionel Galicier
- Department of Clinical Immunology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Bertrand Arnulf
- Department of Immuno-Hematology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Véronique Meignin
- Department of Pathology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Jérôme Vérine
- Department of Pathology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Alfred Mahr
- Department of Internal Medicine, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Élie Azoulay
- Department of Medical Intensive Care Unit, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
- AP-HP, Hôpital Saint-Louis, Medical ICU, University Paris-7 Paris-Diderot, UFR de Médecine, 1 avenue Claude Vellefaux, 75010 Paris, France
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Lee J, Yim JJ, Yang SC, Yoo CG, Kim YW, Han SK, Lee EY, Lee EB, Song YW, Lee SM. Outcome of patients with connective tissue disease requiring intensive care for respiratory failure. Rheumatol Int 2011; 32:3353-8. [PMID: 21947378 DOI: 10.1007/s00296-011-2158-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Accepted: 09/10/2011] [Indexed: 11/24/2022]
Abstract
Occasionally acute respiratory failure (ARF) develops in patients with connective tissue disease (CTD), but the etiologies of ARF in these patients are not fully elucidated. The objective of this study is to find out the causes of ARF leading to intensive care unit (ICU) admission in these patients and to assess their clinical outcome. The medical records of 1,870 consecutive patients admitted to the ICU in Seoul National University Hospital since January 2005-September 2008 were reviewed. A total of 66 patients with CTD were analyzed. The median age was 58 years, and 45 patients were women. The median length of ICU stay was 16 days with a median duration of mechanical ventilation support of 15 days. The distribution of underlying CTD was 17 patients with systemic lupus erythematosus; 15 with rheumatoid arthritis; 14 with systemic vasculitis; and nine with polymyositis-dermatomyositis. Pneumonia was the leading cause of ARF in 24 patients (36%). We could not identify the cause of ARF in 14. Other causes of ARF were acute pulmonary edema for nine patients, diffuse alveolar hemorrhage for eight and Pneumocystis pneumonia for four. Forty-one patients (62%) died during admission, and the mortality rate was the lowest in those with acute pulmonary edema. Use of norepinephrine was statistically higher in nonsurvivors. We could identify the cause of ARF leading to ICU admission in at least 80% of patients with CTD. However, these patients still showed a high mortality rate regardless of etiology. Their survival might be influenced by hemodynamic status.
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Affiliation(s)
- Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute of Medical Research Center, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea
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Buendía-Roldán I, Navarro C, Rojas-Serrano J. [Diffuse alveolar hemorrhage: Causes and outcomes in a referral center]. REUMATOLOGIA CLINICA 2011; 6:196-8. [PMID: 21794712 DOI: 10.1016/j.reuma.2009.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 07/09/2009] [Accepted: 07/09/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To identify the most common causes of diffuse alveolar hemorrhage (DAH) and the evolution of cases during hospitalization. PATIENTS AND METHODS A review of cases diagnosed with DAH; the diagnoses were classified according to existing criteria and the progression of the cases was determined. RESULTS We identified 17 cases of DAH, with the leading cause being ANCA associated vasculitis (41% of cases), followed by cases secondary to drugs (18%). In 35% of the cases, there was a failure in identifying an etiology. Six patients died (35%), the only factor associated with mortality was male gender 5/6 vs 3/11, p=0.05. CONCLUSIONS The most frequent cause of alveolar hemorrhage was ANCA associated vasculitis. The mortality in DAH is about 35%, males seem to have a worse prognosis.
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Affiliation(s)
- Ivette Buendía-Roldán
- Instituto Nacional de Enfermedades Respiratorias Dr. Ismael Cosio Villegas, Facultad de Medicina, Universidad Nacional Autónoma de México, México
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Masjedi MR, Tafti SF, Cheraghvandi A, Fayazi N, Talischi F, Mokri B. Churg-Strauss syndrome following cessation of allergic desensitization vaccination: a case report. J Med Case Rep 2010; 4:188. [PMID: 20565986 PMCID: PMC2904789 DOI: 10.1186/1752-1947-4-188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2009] [Accepted: 06/22/2010] [Indexed: 12/28/2022] Open
Abstract
Introduction Churg-Strauss syndrome is a vasculitis of medium to small sized vessels. Diagnosis is mainly clinical with findings of asthma, eosinophilia, rhinosinusitis and signs of vasculitis in major organs. Case presentation We present a case of a 19-year-old Persian male who developed signs and symptoms of this syndrome related to hyposensitization treatments for allergy control. Conclusions No unifying etiology for the disease can be presented as it is found associated with environmental factors, medications, infections and is even considered a variant of asthma with predisposition to vasculitic involvement. Therefore, it is important to recognize this disease and be aware of underdiagnosis because of emphasis on pathologic evidence. Here, we present a case of allergic desensitization causing Churg-Strauss syndrome in the absence of other known factors.
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Affiliation(s)
- Mohammad Reza Masjedi
- Massih Daneshvari Hospital, Department of Pulmonary Medicine, Tobacco Prevention and Control Research Center (TPCRC), National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, DarAbad, Tehran, Postal Code 1955841452, Iran.
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Frausova D, Brejnikova M, Hruskova Z, Rihova Z, Tesar V. Outcome of thirty patients with ANCA-associated renal vasculitis admitted to the intensive care unit. Ren Fail 2009; 30:890-5. [PMID: 18925529 DOI: 10.1080/08860220802353892] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The natural course of as-yet-untreated ANCA-associated vasculitis (AAV) or complications of immunosuppressive treatment may result in rapid clinical deterioration with the need of admission to an intensive care unit (ICU). The aim of this retrospective study was to assess the outcome of patients with renal AAV admitted to the ICU in a single center. We reviewed the medical records of all 218 patients with AAV followed in our department between January 2001 and December 2006 and selected those admitted to the ICU. To assess the severity of critical illness, the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) score on the first ICU day were calculated. Birmingham Vasculitis Activity Score (BVAS) was calculated to represent the total disease activity. Thirty patients with AAV (11 women, 19 men; mean age 61.5 +/- 13.2 years; 20 x cANCA, 10 x pANCA positive) were included. The most common reasons for ICU admission were as follows: active vasculitis (13 patients, 43.3 %), infections (7 patients, 23.3%), and other causes (10 patients, 33.3%). The in-ICU mortality was 33.3% (10 patients). The most common cause of death was septic shock (in 5 patients). The APACHE II (33.5 vs. 23.8) and SOFA scores (11.9 vs. 6.6), but not BVAS (11.5 vs. 16.1), were statistically significantly higher in non-survivors than in survivors (p < 0.01). In conclusion, the in-ICU mortality in AAV patients may be predicted by APACHE II and SOFA scores. While active vasculitis is the most frequent reason for ICU admission, the mortality rate is highest in patients with infectious complications.
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Affiliation(s)
- Doubravka Frausova
- Department of Nephrology, General Teaching Hospital and First Faculty of Medicine, Charles University in Prague, Czech Republic.
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Manna R, Cadoni G, Ferri E, Verrecchia E, Giovinale M, Fonnesu C, Calò L, Armato E, Paludetti G. Wegener's granulomatosis: an update on diagnosis and therapy. Expert Rev Clin Immunol 2008; 4:481-95. [PMID: 20477576 DOI: 10.1586/1744666x.4.4.481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Wegener's granulomatosis (WG) is a unique clinicopathological disease characterized by necrotizing granulomatous vasculitis of the respiratory tract, pauci-immune necrotizing glomerulonephritis and small-vessel vasculitis. Owing to its wide range of clinical manifestations, WG has a broad spectrum of severity that includes the potential for alveolar hemorrhage or rapidly progressive glomerulonephritis, which are immediately life threatening. WG is associated with the presence of circulating antineutrophil cytoplasm antibodies (c-ANCAs). The most widely accepted pathogenetic model suggests that c-ANCA-activated cytokine-primed neutrophils induce microvascular damage and a rapid escalation of inflammation with recruitment of mononuclear cells. The diagnosis of WG is made on the basis of typical clinical and radiologic findings, by biopsy of involved organ, the presence of c-ANCA and exclusion of all other small-vessel vasculitis. Currently, a regimen consisting of daily cyclophosphamide and corticosteroids is considered standard therapy. A number of trials have evaluated the efficacy of less-toxic immunosuppressants and antibacterials for treating patients with WG, resulting in the identification of effective alternative regimens to induce or maintain remission in certain subpopulations of patients. Recent investigation has focused on other immunomodulatory agents (e.g., TNF-alpha inhibitors and anti-CD20 antibodies), intravenous immunoglobulins and antithymocyte globulins for treating patients with resistant WG.
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Affiliation(s)
- R Manna
- Clinical Autoimmunity Unit, Department of Internal Medicine, Catholic University of the Sacred Heart, Largo A Gemelli, 8-00168 Rome, Italy.
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Khan SA, Subla MR, Behl D, Specks U, Afessa B. Outcome of Patients With Small-Vessel Vasculitis Admitted to a Medical ICU. Chest 2007; 131:972-6. [PMID: 17426197 DOI: 10.1378/chest.06-2464] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSES This study aims to describe the clinical course and prognostic factors of patients with small-vessel vasculitis admitted to a medical ICU. METHODS We reviewed the clinical records of 38 patients with small-vessel vasculitis admitted consecutively to the ICU between January 1997 and May 2004. The APACHE (acute physiology and chronic health evaluation) III prognostic system was used to determine the severity of illness on the first ICU day; the sequential organ failure assessment (SOFA) score was used to measure organ dysfunction, and the Birmingham vasculitis activity score for Wegener granulomatosis (BVAS/WG) was used to assess vasculitis activity. Outcome measures were the 28-day mortality and ICU length of stay. RESULTS Nineteen patients (50%) had Wegener granulomatosis, 16 patients (42%) had microscopic polyangiitis, 2 patients had CNS vasculitis, and 1 patient had Churg-Strauss syndrome. Reasons for ICU admission included alveolar hemorrhage in 14 patients (37%), sepsis in 5 patients (13%), seizures in 3 patients (8%), and pneumonia in 2 patients (5%). The median ICU length of stay was 4.0 days (interquartile range, 2.0 to 6.0 days). The APACHE III score was lower in survivors than nonsurvivors (p = 0.010). The predicted hospital mortality was 54% for nonsurvivors and 21% for survivors (p = 0.0038). The mean SOFA score was 11.6 (SD, 2.6) in nonsurvivors, compared to 6.9 (SD, 2.4) in survivors (p = 0.0004). Mean BVAS/WG scores were 8.6 (SD, 3.6) in nonsurvivors and 4.7 (SD, 4.6) in survivors (p = 0.0889). Twenty-six percent of the patients received invasive mechanical ventilation, and 33% underwent dialysis. The 28-day and 1-year mortality rates were 11% and 29%, respectively. CONCLUSIONS The mortality of patients with small-vessel vasculitis admitted to the ICU is lower than predicted, and alveolar hemorrhage is the most common reason for ICU admission.
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Affiliation(s)
- S Anjum Khan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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