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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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2
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Liu X, Xia M, Liu D, Liu H, Tang C, Chen G, Liu Y, Yuan F, Liu H. Efficacy of protein A immunoadsorption and therapeutic plasma exchange in ANCA-associated vasculitis with severe renal involvement: a retrospective study. Ann Med 2023; 55:2230875. [PMID: 37452682 PMCID: PMC10351471 DOI: 10.1080/07853890.2023.2230875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 03/25/2023] [Accepted: 06/24/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Severe renal impairment is a common complication of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and is associated with poor prognosis and shorter survival. It is urgent to find effective treatments to improve the prognosis of AAV patients. This study was designed to assess the efficacy and safety of protein A immunoadsorption (PAIA) and therapeutic plasma exchange (TPE) for AAV with severe renal involvement. METHODS A total of 48 AAV patients with renal involvement admitted to the Second Xiangya Hospital from January 2018 to February 2021 were selected. Clinical data, myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA), remission at 6 months, and outcomes were evaluated. The primary outcomes of interest were death and renal survival as defined by the occurrence of end-stage renal disease (ESRD). RESULTS PAIA was effective in the removal of MPO-ANCA and IgG, and showed superior over TPE in the clearance of MPO-ANCA within 1 month after treatment. After a median follow-up of 14.5 months, PAIA therapy showed an advantage in reducing mortality over TPE. There was no difference in the development of ESRD between the two groups. Multivariate Cox regression analysis indicated that higher serum creatinine (SCr) and lower haemoglobin level were independent risks of ESRD. Age > 60, lower serum albumin (ALB), and failure to achieve remission at 6 months were independent risks of death. CONCLUSIONS PAIA treatment reduces MPO-ANCA and IgG as well as mortality in AAV patients, and may be beneficial for severe AAV in clinical practice. Higher SCr, lower serum ALB or haemoglobin levels, age > 60, and failure to achieve remission at 6 months independently predict the ESRD or death of AAV patients with severe renal involvement.KEY MESSAGESCompared with therapeutic plasma exchange, protein A immunoadsorption treatment eliminates myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) and IgG better and reduces mortality in ANCA-associated vasculitis (AAV) patients with severe renal involvement.Higher serum creatinine, lower serum albumin or haemoglobin levels, age > 60, and failure to achieve remission at 6 months independently predict the end-stage renal disease (ESRD) or death of AAV patients with severe renal involvement.
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Affiliation(s)
- Xiaojuan Liu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, China
| | - Ming Xia
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, China
| | - Di Liu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, China
| | - Haiyang Liu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, China
| | - Chengyuan Tang
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, China
| | - Guochun Chen
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, China
| | - Yu Liu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, China
| | - Fang Yuan
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, China
| | - Hong Liu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, China
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He X, Jiang L, Hu L, Du P, Zhu M, Wu H, Zhao M, Lu Q. Mivebresib alleviates systemic lupus erythematosus-associated diffuse alveolar hemorrhage via inhibiting infiltration of monocytes and M1 polarization of macrophages. Int Immunopharmacol 2023; 120:110305. [PMID: 37182455 DOI: 10.1016/j.intimp.2023.110305] [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: 02/13/2023] [Revised: 04/23/2023] [Accepted: 05/05/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is a serious complication that can arise from systemic lupus erythematosus (SLE) and other autoimmune diseases. While current treatments for DAH have limitations and adverse side effects, recent evidence suggests that inflammatory macrophages play a crucial role in the development of DAH. In this study, we investigated Mivebresib, a BET protein-bromodomain-containing protein 4 (BRD4) inhibitor, as a potential treatment for DAH. RESULTS Our findings show that Mivebresib effectively protected C57BL/6J mice against pristane-induced DAH by inhibiting the migration and polarization of monocytes and macrophages, as well as pathogenic B and T cells. Specifically, Mivebresib modified the distribution of leukocytes, impeded the polarization of inflammatory macrophages, and reduced the frequency of CD19 + CD5 + B cells in the lungs of pristane-treated mice. Furthermore, in vitro experiments demonstrated that Mivebresib inhibited LPS-induced M1 polarization of macrophages and the expression of pro-inflammatory cytokines, M1 marker genes, and chemokines-chemokine receptors while thwarting the secretion of IL-6 and TNF-α. Transcriptomic analysis suggested and experiments comfimed that Mivebresib inhibits M1 polarization via interrupting the p300/BRD4/HIF1A axis. CONCLUSIONS Our study demonstrates that Mivebresib has therapeutic potential for the life-threatening complication of DAH caused by SLE. By inhibiting macrophage polarization and the infiltration of inflammatory cells, Mivebresib may offer a promising treatment option for patients suffering from this disease.
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Affiliation(s)
- Xieling He
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Li Jiang
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Longyuan Hu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Pei Du
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ming Zhu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Haijing Wu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ming Zhao
- Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences, Nanjing, China; Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China; Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China; Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital, Central South University, Changsha, China.
| | - Qianjin Lu
- Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences, Nanjing, China; Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China; Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China; Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital, Central South University, Changsha, China.
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Alqatari S, Hasan M, Bukhari R, Hadhiah K, Alwaheed A, Alabdrabalnabi F, Al Ohaid F, Aldarwish AW. A young female with hypocomplementemic urticarial vasculitis associated with a rare CNS manifestation. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2023. [DOI: 10.29333/ejgm/12859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This case report represents a rare case of 14-year-old female who diagnosed with hypocompementemic urticarial vasculitis syndrome that presents with glomerulonephritis, diffuse alveolar hemorrhage, and acute disseminated encephalomyelitis. The progression of the symptoms explained in the text below in which the final diagnosis was reached after a challenging approach. Patient was managed properly and followed up after treating with rituximab, although she represents no sign of the disease after a total of two cycles.
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Affiliation(s)
- Safi Alqatari
- Internal Medicine and Rheumatology, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, SAUDI ARABIA
| | - Manal Hasan
- Internal Medicine and Rheumatology, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, SAUDI ARABIA
| | - Raed Bukhari
- Internal Medicine and Rheumatology, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, SAUDI ARABIA
| | - Kawther Hadhiah
- Neurology, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, SAUDI ARABIA
| | - Abrar Alwaheed
- Internal Medicine and Hematology, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, SAUDI ARABIA
| | | | - Fatimah Al Ohaid
- General Medicine, Saud Al Babtain Cardiac Hospital, Dammam, SAUDI ARABIA
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5
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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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Ohta S, Matsuyoshi T, Kaneko H, Kosen D, Suzuki H, Hamaguchi J, Sato Y, Shimizu K. Venovenous Extracorporeal Membrane Oxygenation in Diffuse Alveolar Hemorrhage Secondary to Anti-neutrophil Cytoplasmic Autoantibody-associated Vasculitis: Starting without Systemic Anticoagulation. Intern Med 2022; 61:3569-3573. [PMID: 35569985 PMCID: PMC9790777 DOI: 10.2169/internalmedicine.9472-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Regarding extracorporeal membrane oxygenation (ECMO) support against hemorrhagic conditions, there seems to be a dilemma when deciding between maintaining the circuit patency by systemic anticoagulation and increasing the risk of bleeding. We herein report two cases of diffuse alveolar hemorrhage (DAH) caused by myeloperoxidase (MPO) anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV) successfully treated with venovenous (VV)-ECMO support, both initially started without systemic anticoagulation. Under anticoagulation-free ECMO management, we should consider the shortcomings of frequent circuit exchange and hemorrhagic diathesis related to circuit-induced disseminated intravascular coagulation (DIC).
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Affiliation(s)
- Soichi Ohta
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Takeo Matsuyoshi
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Hitoshi Kaneko
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Daiyu Kosen
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Hiroaki Suzuki
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Jun Hamaguchi
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Yuichi Sato
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
| | - Keiki Shimizu
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Japan
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Assan F, Bay P, Mathian A, Hekimian G, Bréchot N, Quentric P, Moyon Q, Schmidt M, Cohen-Aubart F, Haroche J, Amoura Z, Luyt CE, Combes A, Pineton de Chambrun M. In-ICU-acquired infections in flare-up systemic rheumatic disease patients receiving immunosuppressant. Clin Rheumatol 2022; 41:2845-2854. [PMID: 35534696 DOI: 10.1007/s10067-022-06197-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/25/2022] [Accepted: 04/30/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Systemic rheumatic diseases (SRDs) are a group of inflammatory disorders that can need intensive care unit (ICU) admission during a flare-up, requiring administration of immunosuppressants. We undertook this study to determine the frequency, outcome, and occurrence associated factors of infections in flare-up SRD patients receiving immunosuppressant. METHODS Monocenter, a retrospective study including SRD patients admitted to ICU for a flare-up requiring immunosuppressant from 2004 to 2019. The primary endpoint was in-ICU-acquired infections. RESULTS Ninety-eight patients (female/male ratio: 1.6; mean age at admission: 39.5 ± 17.4 years) were admitted to the ICU for a SRD flare-up, inaugural in 61.2% cases. A specific treatment was given to every patient: corticosteroids 100%, cyclophosphamide 45.9%, plasma exchange 46.9%. Ninety-five infections occurred in 35 (36%) patients mainly pneumonias. The overall in-hospital mortality was 17.3%, and 46% of patients with a nosocomial infection died during their ICU stay. The logistic regression multivariable model retained renal replacement therapy and mechanical ventilation as independent predictors of infection. CONCLUSION In-ICU-acquired infection in SRD flare-up is a frequent event associated with organ failures but not with in-ICU use of immunosuppressants. These data suggest that the fear of infection should not withhold a careful in-ICU use of immunosuppressive drugs. Key Points • In-ICU infections are frequent in flare-up systemic rheumatic disease patients. • Infections are associated with increased mortality. • Cyclophosphamide given in ICU was not independently associated with infection. • Severe neutropenia occurred in 27% of patients receiving cyclophosphamide in ICU.
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Affiliation(s)
- Florence Assan
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Pierre Bay
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Alexis Mathian
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Guillaume Hekimian
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Nicolas Bréchot
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Paul Quentric
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France.,Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Inserm, Paris, France
| | - Quentin Moyon
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France.,Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France.,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France
| | - Fleur Cohen-Aubart
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Julien Haroche
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Zahir Amoura
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France.,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France.,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France
| | - Marc Pineton de Chambrun
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France. .,Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France. .,Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Inserm, Paris, France. .,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France.
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8
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Sharma A, Upadhyay B, Banjade R, Poudel B, Luitel P, Kharel B. A Case of Diffuse Alveolar Hemorrhage With COVID-19 Vaccination. Cureus 2022; 14:e21665. [PMID: 35233333 PMCID: PMC8881991 DOI: 10.7759/cureus.21665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2022] [Indexed: 12/14/2022] Open
Abstract
With the growing rates of vaccination against coronavirus disease 2019 (COVID-19) across the globe, rare side effects have been increasingly noticed on a post-marketing basis. Cases of myocarditis and pericarditis have been reported in the literature following COVID messenger RNA (mRNA) vaccination. However, diffuse alveolar hemorrhage (DAH) following vaccination has not been reported. DAH is a life-threatening clinicopathological entity characterized by bleeding into the alveolar space from pulmonary microvasculature. It presents a diagnostic challenge in the setting of acute respiratory failure, requiring prompt suspicion and workup. We report a case of a 59-year-old male with a recent COVID-19 infection who presented with DAH within eight hours of the first dose of mRNA vaccination (Moderna, Cambridge, MA). Bronchial alveolar lavage was performed, along with imaging of the chest, to confirm the diagnosis. Immunological workup with rheumatoid factor, anti-citrullinated peptide, anti-neutrophil cytoplasmic antibodies (P-ANCA and C-ANCA), anti-glomerular basement antibodies, Anti-double-stranded DNA, C3 and C4 complement levels, and cryoglobulin were all negative. Infectious workup with cultures and PCR from bronchial lavage was also negative. In the absence of any other causes, the etiology was likely deemed to be vaccine-induced DAH. Herein, we also discuss the possible mechanism of vaccine-related DAH and emphasize the need for further studies on vaccine-related adverse events.
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Affiliation(s)
- Alisha Sharma
- Internal Medicine, AMITA Health Saint Francis Hospital, Evanston, USA
| | - Binayak Upadhyay
- Internal Medicine, Divison of Hospital Medicine, University of Kentucky College of Medicine, Lexington, USA
| | - Rabin Banjade
- Internal medicine, AMITA Health Saint Francis hospital, Evanston, USA
| | - Bidhya Poudel
- Internal Medicine, AMITA Health Saint Francis Hospital, Evanston, USA
| | - Pankaj Luitel
- Internal Medicine, AMITA Health Saint Francis Hospital, Evanston, USA
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9
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Selickman J, Fiocchi J, Desai H, Pendleton KM. Successful hemostasis in refractory alveolar hemorrhage using low-dose recombinant activated factor VII. Respir Med Case Rep 2022; 39:101742. [PMID: 36161235 PMCID: PMC9493381 DOI: 10.1016/j.rmcr.2022.101742] [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: 07/22/2022] [Revised: 08/16/2022] [Accepted: 09/15/2022] [Indexed: 11/26/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening condition requiring prompt recognition. Conventional therapy, even when initiated early, may not have an immediate effect, and in severe cases, bleeding can persist despite treatment. We report the case of a previously healthy 33-year-old male who developed DAH secondary to granulomatosis with polyangiitis, resulting in respiratory failure and the need for mechanical ventilation. High-dose corticosteroids, plasma exchange, and remission induction with cyclophosphamide failed to control bleeding, leading to severely impaired gas exchange. 20 mcg/kg of systemic recombinant activated Factor VII (rFVIIa), a dose lower than previously reported for management of DAH, resulted in hemostasis and improved oxygenation after only three doses. No complications were observed, and our patient was liberated from ventilatory support eight days later. In the setting of DAH with refractory bleeding, hemostasis may be achievable with a lower dose of rFVIIa than commonly used, potentially mitigating the risk of dose-dependent side effects.
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10
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Qi Y, Wang L, Qian L, Zhang X. The etiology, clinical profile, and outcome of diffuse alveolar hemorrhage in children: a ten-year single-center experience. Transl Pediatr 2021; 10:2921-2928. [PMID: 34976758 PMCID: PMC8649607 DOI: 10.21037/tp-21-283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/13/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is a life-threatening syndrome that may be caused by numerous disorders. There is scant data on the etiology and characteristics of DAH in children. METHODS We retrospectively reviewed the clinical records of patients admitted to a tertiary pediatric hospital with DAH over a 10-year period. The syndrome was classified into five groups according to different etiologies, and the characteristics and outcomes of patients were compared. RESULTS A total of 74 children were included in the study. Idiopathic pulmonary hemosiderosis (IPH) was the most frequent cause (64.9%), followed by miscellaneous causes (infection and other conditions) (16.2%), immune-mediated disorders (9.5%), liver dysfunction (5.4%), and cardiovascular disorders (4.1%). The median age of the patients was 3.5 years (ranging from 1.5 to 7 years), and no difference was found in the proportion of fever, crackles, and pulmonary infiltrates among the five etiological groups. There was no difference in the proportion of blood transfusions among the groups. Cardiac catheterization was performed on 31 patients for whom the diagnostic workup was negative and were suspected of having IPH, and abnormal signs were observed and bronchial artery embolization (BAE) was performed in all those patients. The patients with IPH had the lowest mortality, while those with DAH secondary to liver failure had the highest mortality. Patients in BAE group had a shorter duration of corticosteroids and a lower relapse rate than non-BAE group. CONCLUSIONS Idiopathic pulmonary hemosiderosis is a common etiology of DAH and has a good prognosis in children. Vascular abnormalities were observed in the patients with IPH. Further studies are needed to clarify the role of vascular malformations in IPH.
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Affiliation(s)
- Yuanyuan Qi
- Department of Respiratory Disease, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Libo Wang
- Department of Respiratory Disease, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Liling Qian
- Department of Respiratory Disease, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Xiaobo Zhang
- Department of Respiratory Disease, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
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11
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Kanaoka K, Minami S, Ihara S, Komuta K. High neutrophils and low lymphocytes percentages in bronchoalveolar lavage fluid are prognostic factors of higher in-hospital mortality in diffuse alveolar hemorrhage. BMC Pulm Med 2021; 21:288. [PMID: 34503470 PMCID: PMC8431931 DOI: 10.1186/s12890-021-01660-x] [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: 05/03/2021] [Accepted: 09/01/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is a syndrome resulting from bleeding in the microcirculation of the lung, with a poor prognosis. The study aim was to identify prognostic factors of DAH, especially bronchoalveolar lavage fluids (BALF) cell pattern. METHODS We conducted a single-center retrospective cohort study of patients diagnosed as having DAH and hospitalized at our hospital between October 2008 and July 2020. We performed univariate logistic regressions to identify variables associated with in-hospital death. RESULTS Sixty-eight patients were included in our analysis. In-hospital mortality was 26.5%. Variables associated with in-hospital death were neutrophils percentage in BALF ≥ 44.5% [Odds Ratio (OR) 16.0, 95% confidence interval (CI) 4.33-58.9)], lymphocytes percentage in BALF < 14% (OR 7.44, 95% CI 2.11-26.2), idiopathic DAH (OR 0.31, 95% CI 0.10-0.95), oxygen flow ≥ 4L/min (OR 3.90, 95% CI 1.20-12.6), and estimated glomerular filtration rate < 60 mL/min (OR 5.00, 95%CI 1.29-19.4). CONCLUSIONS High neutrophils and low lymphocytes percentages in BALF were associated with poor prognosis.
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Affiliation(s)
- Kensuke Kanaoka
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31, Kitayama-cho, Tennoji-ku, Osaka-City, Osaka, 543-0035, Japan
| | - Seigo Minami
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31, Kitayama-cho, Tennoji-ku, Osaka-City, Osaka, 543-0035, Japan.
| | - Shoichi Ihara
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31, Kitayama-cho, Tennoji-ku, Osaka-City, Osaka, 543-0035, Japan
| | - Kiyoshi Komuta
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31, Kitayama-cho, Tennoji-ku, Osaka-City, Osaka, 543-0035, Japan
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12
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Rubin J, Sclafani A, Helland TL, Sharma A, Maley JH, Peck TJ, Wallwork RS, Bolster MB, Berigei S, Colson YL, Selig MK, Mino-Kenudson M, Hariri LP. Pulmonary Hemosiderosis with Calcification Associated with IgA Nephropathy. Am J Respir Crit Care Med 2021; 204:e24-e25. [PMID: 33626295 DOI: 10.1164/rccm.202009-3391im] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jonah Rubin
- Division of Pulmonary and Critical Care, Department of Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Alyssa Sclafani
- Division of Pulmonary and Critical Care, Department of Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Timothy L Helland
- Department of Pathology.,Harvard Medical School, Boston, Massachusetts
| | - Amita Sharma
- Department of Radiology.,Harvard Medical School, Boston, Massachusetts
| | - Jason H Maley
- Division of Pulmonary and Critical Care, Department of Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Tyler J Peck
- Division of Pulmonary and Critical Care, Department of Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Rachel S Wallwork
- Division of Rheumatology, Department of Medicine, and.,Harvard Medical School, Boston, Massachusetts
| | - Marcy B Bolster
- Division of Rheumatology, Department of Medicine, and.,Harvard Medical School, Boston, Massachusetts
| | - Sarita Berigei
- Division of Pulmonary and Critical Care, Department of Medicine
| | - Yolonda L Colson
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; and.,Harvard Medical School, Boston, Massachusetts
| | | | | | - Lida P Hariri
- Division of Pulmonary and Critical Care, Department of Medicine.,Department of Pathology.,Harvard Medical School, Boston, Massachusetts
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13
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Samuel S, Brown B, Mason N, Abdo T. Diffuse alveolar hemorrhage, a rare presentation of polymyositis. Respir Med Case Rep 2020; 31:101261. [PMID: 33145158 PMCID: PMC7593619 DOI: 10.1016/j.rmcr.2020.101261] [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: 07/11/2020] [Revised: 09/15/2020] [Accepted: 10/10/2020] [Indexed: 02/07/2023] Open
Abstract
Background Diffuse alveolar hemorrhage is a medical emergency caused by persistent and recurrent pulmonary hemorrhage [1]. It is an uncommon presentation of polymyositis. Symptoms of polymyositis include fatigue, muscle pains, proximal muscle weakness, and joint pains [2]. Case presentation A 44-year-old male presented with new onset shortness of breath and productive cough with white sputum and occasional hemoptysis. The patient was diagnosed with diffuse alveolar hemorrhage (DAH) via bronchoscopy and discharged initially on prednisone. The patient's laboratory work indicated positive titers of ANA & anti-Jo-1 antibody with low complement levels. These results pointed towards the diagnosis of polymyositis [3]. DAH can also be caused by systemic lupus erythematosus, Goodpasture's syndrome, Sjogren syndrome, anticoagulant therapy, and antiphospholipid antibody syndrome [4]. However, the possibility of these potential causes was excluded. Conclusion This case of diffuse alveolar hemorrhage was most likely due to polymyositis.
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Affiliation(s)
- Sharoon Samuel
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, USA
| | - Brent Brown
- Department of Pulmonary & Critical Care, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | - Nita Mason
- Department of Radiological Sciences, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | - Tony Abdo
- Department of Pulmonary & Critical Care, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
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