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Fiorino EK, Fishman MP. Approach to the patient with Childhood Interstitial and Diffuse Lung Disease. Pediatr Pulmonol 2024; 59:2267-2275. [PMID: 39056528 DOI: 10.1002/ppul.27162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 06/06/2024] [Accepted: 06/25/2024] [Indexed: 07/28/2024]
Abstract
Childhood Interstitial and Diffuse Lung Disease (chILD) encompasses a group of rare, chronic lung disorders in infants and children with overlapping clinical features but diverse etiologies. The clinical presentation of chILD is of chronic or recurring respiratory signs and symptoms, often including increased work of breathing and hypoxia, with diffuse radiographic abnormalities on chest imaging. Recognition can be challenging since some clinical features overlap with those of more common pediatric respiratory diseases including asthma and recurrent viral infections, among others. chILD should be considered as an underlying diagnosis when a patient's respiratory symptoms seem disproportionate to the clinical scenario and/or persist. The diagnostic process involves multiple steps and is tailored to the individual patient. Nearly all children will undergo imaging and pulmonary function testing, many will undergo bronchoscopy with bronchoalveolar lavage, many will receive genetic testing, and some will require lung biopsy. Treatment includes preventive care, evaluation for comorbidities, pharmacotherapy according to diagnosis, and ongoing disease surveillance, including revisiting genetic and histopathologic results as new clinical information becomes available and as our understanding of these rare disorders improves. The purpose of this review is to provide a broad approach to the diagnosis and management of patients with chILD.
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Affiliation(s)
- Elizabeth K Fiorino
- Northwell, New Hyde Park, New York, USA
- Departments of Science Education and Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Martha P Fishman
- Harvard Medical School, Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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2
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Samad A, Wobma H, Casey A. Innovations in the care of childhood interstitial lung disease associated with connective tissue disease and immune-mediated disorders. Pediatr Pulmonol 2024; 59:2321-2337. [PMID: 38837875 DOI: 10.1002/ppul.27068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 04/05/2024] [Accepted: 05/07/2024] [Indexed: 06/07/2024]
Abstract
Childhood interstitial lung disease (chILD) associated with connective tissue and immune mediated disorders is the second most common chILD diagnostic category. As knowledge of the molecular and genetic underpinnings of these rare disorders advances, the recognized clinical spectrum of associated pulmonary manifestations continues to expand. Pulmonary complications of these diseases, including ILD, confer increased risk for morbidity and mortality and contribute to increased complexity for providers tasked with managing the multiple organ systems that can be impacted in these systemic disorders. While pulmonologists play an important role in diagnosis and management of these conditions, thankfully they do not have to work alone. In collaboration with a multidisciplinary team of subspecialists, the pulmonary and other systemic manifestations of these conditions can be managed effectively together. The goal of this review is to familiarize the reader with the classic patterns of chILD and other pulmonary complications associated with primary immune-mediated disorders (monogenic inborn errors of immunity) and acquired systemic autoimmune and autoinflammatory diseases. In addition, this review will highlight current, emerging, and innovative therapeutic strategies and will underscore the important role of multidisciplinary management to improving outcomes for these patients.
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Affiliation(s)
- Aaida Samad
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Holly Wobma
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alicia Casey
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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3
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Nguyen HN, Salman R, Vogel TP, Silva-Carmona M, DeGuzman M, Guillerman RP. Imaging findings of COPA Syndrome. Pediatr Radiol 2023; 53:844-853. [PMID: 36746811 DOI: 10.1007/s00247-023-05600-1] [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: 08/31/2022] [Revised: 12/21/2022] [Accepted: 01/11/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Autosomal dominant mutations in the coatomer-associated protein alpha (COPA) gene cause an immune dysregulation disorder associated with pulmonary hemorrhage, lymphoid hyperplasia, arthritis, and glomerulonephritis. OBJECTIVE To describe the thoracic, musculoskeletal, and renal imaging findings of COPA syndrome with a focus on the evolution of the pulmonary findings. MATERIALS AND METHODS With approval of the Institutional Review Board, consensus retrospective review of findings on chest radiography and computed tomography (CT), musculoskeletal radiography and magnetic resonance imaging (MRI), and renal ultrasound (US) was performed for pediatric COPA syndrome patients. COPA syndrome patients < 18 years of age presenting between 1992 and 2019 were identified from an institutional rheumatology registry. RESULTS Twelve pediatric COPA syndrome patients (mean age of 6.5 years at first imaging exam; 6 females) were identified. Imaging exams available for review included 45 chest CT exams on 12 patients, 37 musculoskeletal exams on 4 patients, and 10 renal US exams on 5 patients. All 12 had abnormal chest CT exams, with findings including ground-glass opacities (12/12), cysts (8/12), septal thickening (9/12), nodules (8/12), fibrosis (7/12), crazy-paving (2/12), consolidation (1/12), hilar/mediastinal lymphadenopathy (11/12), and chest wall deformity (5/12). Nine had at least one follow-up chest CT, which showed improvement in nodules (7/9), ground-glass opacities (4/9), and lymphadenopathy (9/9), but worsening of septal thickening (3/9), cyst formation (3/9), and fibrosis (3/9). Four had musculoskeletal imaging revealing synovitis (2/4), bone erosions (1/4), tenosynovitis (1/4), enthesitis (1/4), and subcutaneous nodules (1/4). Five had at least one renal US, revealing renal size abnormalities (4/5) and cortical hyperechogenicity (3/5). CONCLUSION The most prevalent imaging finding of COPA syndrome is diffuse lung disease related to early childhood-onset recurrent pulmonary hemorrhage and lymphoid hyperplasia that may progress to pulmonary fibrosis. Other imaging findings manifesting later in childhood or adolescence relate to arthritis and glomerulonephritis.
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Affiliation(s)
- HaiThuy N Nguyen
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA
| | - Rida Salman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.
| | - Tiphanie P Vogel
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, 77030, USA
- Center for Human Immunobiology, Texas Children's Hospital, Houston, TX, 77030, USA
| | - Manuel Silva-Carmona
- Pulmonary Division, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Marietta DeGuzman
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, 77030, USA
| | - R Paul Guillerman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA
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4
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Sayad E, Vogel TP, Guillerman RP, Spielberg D, McNeill DM, De Guzman M, Orman G, Silva-Carmona M. Pulmonary manifestations and outcomes in paediatric ANCA-associated vasculitis: a single-centre experience. Rheumatology (Oxford) 2021; 60:3199-3208. [PMID: 33355338 DOI: 10.1093/rheumatology/keaa769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 10/12/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES ANCA-associated vasculitis (AAV) usually involves the renal and respiratory systems, but the paediatric literature on pulmonary manifestations and outcomes is limited. We aimed to describe pulmonary manifestations and outcomes after therapy in a cohort of paediatric AAV (pAAV) patients. METHODS A retrospective chart review of all patients <19 years presenting to our institution with AAV between 1/2008 and 2/2018 was conducted. Patient demographics, clinical presentation, diagnostic testing, therapy and pulmonary outcomes over the first 3 years after presentation were evaluated. RESULTS A total of 38 patients were included; all had ANCA positivity by immunofluorescence. A total of 23 had microscopic polyangiitis (MPA), 13 had granulomatosis with polyangiitis and 2 had eosinophilic granulomatosis with polyangiitis. A total of 30 (79%) had pulmonary manifestations, with cough (73%) and pulmonary haemorrhage (67%) being the most common. Abnormalities were noted in 82% of chest CT scans reviewed, with nodules and ground-glass opacities being the most common. At 6, 12 and 36 months follow-up, respectively, 61.8%, 39.4% and 29% of patients continued to show pulmonary manifestations. Five MPA patients with re-haemorrhage are described in detail. CONCLUSION MPA was more common than granulomatosis with polyangiitis, with pulmonary involvement being common in both. MPA patients had more severe pulmonary manifestations. Chest CT revealed abnormal findings in a majority of cases. A subgroup of young MPA patients experienced repeat pulmonary haemorrhage. Treatment modality and response were comparable in different subtypes of AAV, except for this young MPA group. Additional prospective studies are needed to better understand the different phenotypes of pAAV.
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Affiliation(s)
- Edouard Sayad
- Division of Pulmonary Medicine, Baylor College of Medicine.,Texas Children's Hospital
| | - Tiphanie P Vogel
- Texas Children's Hospital.,Division of Rheumatology, Department of Pediatrics
| | - R Paul Guillerman
- Texas Children's Hospital.,Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - David Spielberg
- Division of Pulmonary Medicine, Baylor College of Medicine.,Texas Children's Hospital
| | - David Moreno McNeill
- Division of Pulmonary Medicine, Baylor College of Medicine.,Texas Children's Hospital
| | - Marietta De Guzman
- Texas Children's Hospital.,Division of Rheumatology, Department of Pediatrics
| | - Gunes Orman
- Texas Children's Hospital.,Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Manuel Silva-Carmona
- Division of Pulmonary Medicine, Baylor College of Medicine.,Texas Children's Hospital
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5
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Dorval G, Hadchouel A, Biebuyck-Gougé N, Giniès H, Rabant M, Berteloot L, Berthaud R, Avramescu M, Bader-Meunier B, Boyer O. A diagnostic dilemma in a boy with lupus and dyspnea: Answers. Pediatr Nephrol 2021; 36:853-856. [PMID: 32681275 DOI: 10.1007/s00467-020-04698-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 06/24/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Guillaume Dorval
- AP-HP, Hôpital Universitaire Necker-Enfants Malades, Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Paris, France. .,Université de Paris, Faculté de Médecine, Paris, France.
| | - Alice Hadchouel
- Université de Paris, Faculté de Médecine, Paris, France.,AP-HP, Hôpital Universitaire Necker-Enfants Malades, Service de Pneumologie Pédiatrique, Centre de Référence pour les Maladies Respiratoires Rares de l'Enfant, Paris, France
| | - Nathalie Biebuyck-Gougé
- AP-HP, Hôpital Universitaire Necker-Enfants Malades, Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Paris, France.,Université de Paris, Faculté de Médecine, Paris, France
| | - Henri Giniès
- AP-HP, Hôpital Universitaire Necker-Enfants Malades, Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Paris, France
| | - Marion Rabant
- Université de Paris, Faculté de Médecine, Paris, France.,AP-HP, Hôpital Universitaire Necker-Enfants Malades, Service d'Anatomopathologie, Paris, France
| | - Laureline Berteloot
- Université de Paris, Faculté de Médecine, Paris, France.,AP-HP, Hôpital Universitaire Necker-Enfants Malades, Service d'Imagerie Pédiatrique, Paris, France
| | - Romain Berthaud
- AP-HP, Hôpital Universitaire Necker-Enfants Malades, Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Paris, France.,Université de Paris, Faculté de Médecine, Paris, France
| | - Marina Avramescu
- AP-HP, Hôpital Universitaire Necker-Enfants Malades, Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Paris, France.,Université de Paris, Faculté de Médecine, Paris, France
| | - Brigitte Bader-Meunier
- Université de Paris, Faculté de Médecine, Paris, France.,AP-HP, Hôpital Universitaire Necker-Enfants Malades, Service d'Immunologie et de Rhumatologie Pédiatrique, Paris, France
| | - Olivia Boyer
- AP-HP, Hôpital Universitaire Necker-Enfants Malades, Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Paris, France.,Université de Paris, Faculté de Médecine, Paris, France
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6
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Rajvanshi N, Chacham S, Chegondi M, Goyal JP, Singh S. Pulmonary Hemosiderosis in a Child With Systemic Lupus Erythematosus: A Rare Presentation. Cureus 2020; 12:e7890. [PMID: 32489744 PMCID: PMC7255548 DOI: 10.7759/cureus.7890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Pulmonary hemorrhage is an uncommon manifestation in children and is often associated with systemic lupus erythematosus. We report a case of an adolescent girl who presented to our hospital with recurrent episodes of fever, cough, and breathlessness. Later on, she was diagnosed with pulmonary hemosiderosis as a manifestation of systemic lupus erythematosus. She was started on immunosuppressive therapy initially with prednisolone and subsequently with azathioprine and hydroxychloroquine, which improved the clinical status of the child.
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Affiliation(s)
- Nikhil Rajvanshi
- Pediatrics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Swathi Chacham
- Pediatrics, All India Institute of Medical Sciences, Rishikesh, IND
| | | | - Jagdish P Goyal
- Pediatrics, All India Institute of Medical Sciences, Jodhpur, IND
| | - Surjit Singh
- Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
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7
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Sun Y, Zhou C, Zhao J, Wang Q, Xu D, Zhang S, Shen M, Hou Y, Tian X, Li M, Zeng X. Systemic lupus erythematosus-associated diffuse alveolar hemorrhage: a single-center, matched case-control study in China. Lupus 2020; 29:795-803. [PMID: 32321345 DOI: 10.1177/0961203320920715] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND This study described clinical characteristics and outcome in systemic lupus erythematosus (SLE) patients with diffuse alveolar hemorrhage (DAH), and investigated risk factors and prognostic factors for DAH. METHODS We conducted a retrospective nested case-control analysis in a single-center cohort. We enrolled 94 SLE patients with DAH. For each case of DAH, two age-, sex-, and SLE courses-matched controls were randomly selected from our cohort. All patients were enrolled between 2004 and 2019 and were followed until death, end of registration with the physician's practice, or end of January 2019. We estimated the risk factors for DAH and prognostic factors for mortality using multivariate analysis. RESULTS We included 4744 patients diagnosed with SLE, with 94 cases of DAH, for an incidence rate of 2.0%. DAH may occur in any stage of SLE but mostly in the early phase of disease course. Lupus nephritis (LN) was the most common concomitant involvement at DAH diagnosis. By multivariate analysis, LN, anti-SSA positivity, thrombocytopenia and elevated C-reactive protein (CRP) were significantly associated with DAH in SLE patients. All-cause mortality was increased in SLE with DAH compared with SLE without DAH (adjusted hazard ratio 6.0, 95% confidence interval 2.8-13.0, p < 0.0001). Intravenous cyclophosphamide (CTX) showed an increased tendency for better survival in DAH after adjusting for Systemic Lupus Erythematosus Disease Activity Index 2000, acute kidney injury and mechanical ventilation. CONCLUSIONS LN, anti-SSA positivity, thrombocytopenia and elevated CRP were independent risk factors of DAH in lupus patients. Due to a high early death rate of DAH and little long-term damage, DAH patients may benefit from early diagnosis and intensive treatment, and CTX-based therapy can be a preferential choice.
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Affiliation(s)
- Yiduo Sun
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Cong Zhou
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Dong Xu
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Min Shen
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Yong Hou
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
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8
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[Diffuse alveolar hemorrhage in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21. [PMID: 31506159 PMCID: PMC7390247 DOI: 10.7499/j.issn.1008-8830.2019.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Diffuse alveolar hemorrhage (DAH) is a clinical syndrome with major clinical manifestations of hemoptysis, anemia, and diffuse infiltration in the lung. DAH has a high mortality rate in the acute stage and is a life-threatening emergency in clinical practice. Compared with adult DHA, childhood DHA tends to have a specific spectrum of underlying diseases. It has long been believed that idiopathic pulmonary hemosiderosis (IPH) is the main cause of childhood DAH; however, with the increase in reports of childhood DAH cases, the etiology spectrum of childhood DAH is expanding. The treatment and prognosis of DAH with different etiologies are different. This review article gives a general outline of childhood DAH, with focuses on DAH caused by IPH, systemic lupus erythematosus, anti-neutrophil cytoplasmic antibody-related vasculitis, COPA syndrome, or IgA vasculitis.
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9
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Kraeva VV, Beketova TV. [Pulmonary hemorrhage in rheumatic diseases]. TERAPEVT ARKH 2019; 91:76-83. [PMID: 32598680 DOI: 10.26442/00403660.2019.05.000234] [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: 04/16/2020] [Indexed: 11/22/2022]
Abstract
In the article, we report the causes of pulmonary hemorrhage (PH) according to the literature data and own experience, with an emphasis on patients suffering from rheumatic diseases. Methods of diagnosis and modern approaches to the treatment of PH are analyzed.
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Affiliation(s)
- V V Kraeva
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University)
| | - T V Beketova
- V.A. Nasonova Scientific and Research Institute of Rheumatology
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10
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Blay G, Rodrigues JC, Ferreira JCO, Leal GN, Gormezano NW, Novak GV, Pereira RMR, Terreri MT, Magalhães CS, Molinari BC, Sakamoto AP, Aikawa NE, Campos LMA, Fernandes TAP, Clemente G, Peracchi OAB, Bugni V, Marini R, Sacchetti SB, Carvalho LM, Fraga MM, Castro TCM, Ramos VC, Bonfá E, Silva CA. Diffuse alveolar hemorrhage in childhood-onset systemic lupus erythematosus: a severe disease flare with serious outcome. Adv Rheumatol 2018; 58:39. [PMID: 30657099 DOI: 10.1186/s42358-018-0038-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/16/2018] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To evaluate prevalence, clinical manifestations, laboratory abnormalities and treatment in a multicenter cohort study including 847 childhood-onset systemic lupus erythematosus (cSLE) patients with and without diffuse alveolar hemorrhage (DAH), as well as concomitant parameters of severity. METHODS DAH was defined as the presence of at least three respiratory symptoms/signs associated with diffuse interstitial/alveolar infiltrates on chest x-ray or high-resolution computer tomography and sudden drop in hemoglobin levels. Statistical analysis was performed using Bonferroni correction (p < 0.0022). RESULTS DAH was observed in 19/847 (2.2%) cSLE patients. Cough/dyspnea/tachycardia/hypoxemia occurred in all cSLE patients with DAH. Concomitant parameters of severity observed were: mechanical ventilation in 14/19 (74%), hemoptysis 12/19 (63%), macrophage activation syndrome 2/19 (10%) and death 9/19 (47%). Further analysis of cSLE patients at DAH diagnosis compared to 76 cSLE control patients without DAH with same disease duration [3 (1-151) vs. 4 (1-151) months, p = 0.335], showed higher frequencies of constitutional involvement (74% vs. 10%, p < 0.0001), serositis (63% vs. 6%, p < 0.0001) and sepsis (53% vs. 9%, p < 0.0001) in the DAH group. The median of disease activity score(SLEDAI-2 K) was significantly higher in cSLE patients with DAH [18 (5-40) vs. 6 (0-44), p < 0.0001]. The frequencies of thrombocytopenia (53% vs. 12%, p < 0.0001), intravenous methylprednisolone (95% vs. 16%, p < 0.0001) and intravenous cyclophosphamide (47% vs. 8%, p < 0.0001) were also significantly higher in DAH patients. CONCLUSIONS This was the first study to demonstrate that DAH, although not a disease activity score descriptor, occurred in the context of significant moderate/severe cSLE flare. Importantly, we identified that this condition was associated with serious disease flare complicated by sepsis with high mortality rate.
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Affiliation(s)
- Gabriela Blay
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil.,Pediatric Pulmonology Unit, Children's Institute, FMUSP, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Joaquim C Rodrigues
- Pediatric Pulmonology Unit, Children's Institute, FMUSP, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Juliana C O Ferreira
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Gabriela N Leal
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | | | - Glaucia V Novak
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | | | - Maria T Terreri
- Pediatric Rheumatology Unit, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Claudia S Magalhães
- São Paulo State University (UNESP), Faculdade de Medicina de Botucatu, Sao Paulo, Brazil
| | - Beatriz C Molinari
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Ana P Sakamoto
- Pediatric Rheumatology Unit, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Nadia E Aikawa
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil.,Division of Rheumatology, FMUSP, Sao Paulo, Brazil
| | - Lucia M A Campos
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Taciana A P Fernandes
- São Paulo State University (UNESP), Faculdade de Medicina de Botucatu, Sao Paulo, Brazil
| | - Gleice Clemente
- Pediatric Rheumatology Unit, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Octavio A B Peracchi
- Pediatric Rheumatology Unit, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Vanessa Bugni
- Pediatric Rheumatology Unit, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Roberto Marini
- São Paulo State University of Campinas (UNICAMP), Sao Paulo, Brazil
| | | | - Luciana M Carvalho
- Ribeirão Preto Medical School - University of São Paulo, Sao Paulo, Brazil
| | | | | | - Valéria C Ramos
- Pontifical Catholic University of Sorocaba, Sao Paulo, Brazil
| | - Eloisa Bonfá
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Clovis A Silva
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil. .,Pediatric Pulmonology Unit, Children's Institute, FMUSP, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil.
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Bajantri B, Sapkota B, Venkatram S. Diffuse Alveolar Hemorrhage without Extrapulmonary Manifestations: A Rare Presentation of Lupus. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:218-223. [PMID: 29487279 PMCID: PMC5839422 DOI: 10.12659/ajcr.907148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patient: Female, 31 Final Diagnosis: Lupus DAH Symptoms: Shortness of breath Medication: — Clinical Procedure: — Specialty: Pulmonology
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Affiliation(s)
- Bharat Bajantri
- Division of Pulmonary and Critical Care, Department of Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA
| | - Binita Sapkota
- Department of Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA
| | - Sindhaghatta Venkatram
- Division of Pulmonary and Critical Care, Department of Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA
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Diffuse Alveolar Hemorrhage in Systemic Lupus Erythematosus: Histopathologic Features and Clinical Correlations. Case Rep Pathol 2017; 2017:1936282. [PMID: 28536665 PMCID: PMC5425825 DOI: 10.1155/2017/1936282] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/28/2017] [Accepted: 04/10/2017] [Indexed: 12/04/2022] Open
Abstract
The case of a 16-year-old African-American girl with systemic lupus erythematosus, who developed diffuse alveolar hemorrhage with fatal consequences, is described. Diffuse alveolar hemorrhage is a rare but serious complication of systemic lupus. It occurs in three distinct but overlapping phenotypes, acute capillaritis, bland pulmonary hemorrhage, and diffuse alveolar damage, each of which is associated with a different group of underlying conditions. Diffuse alveolar hemorrhage is a medical emergency: choice of treatment depends on early diagnosis and determination of the underlying etiology. Acute infection, superimposed on diffuse alveolar hemorrhage in the setting of immune compromise, is often a terminal event, as in this case.
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Filocamo G, Torreggiani S, Agostoni C, Esposito S. Lung involvement in childhood onset granulomatosis with polyangiitis. Pediatr Rheumatol Online J 2017; 15:28. [PMID: 28410589 PMCID: PMC5391594 DOI: 10.1186/s12969-017-0150-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/20/2017] [Indexed: 12/25/2022] Open
Abstract
Granulomatosis with polyangiitis is an ANCA-associated systemic vasculitis with a low incidence in the pediatric population. Lung involvement is a common manifestation in children affected by granulomatosis with polyangiitis, both at disease's onset and during flares. Its severity is variable, ranging from asymptomatic pulmonary lesions to dramatic life-threatening clinical presentations such as diffuse alveolar haemorrhage. Several radiologic findings have been described, but the most frequent abnormalities detected are nodular lesions and fixed infiltrates. Interstitial involvement, pleural disease and pulmonary embolism are less common. Histology may show necrotizing or granulomatous vasculitis of small arteries and veins of the lung, but since typical features may be patchy, the site for lung biopsy should be carefully chosen with the help of imaging techniques such as computed tomography. Bronchoalveolar lavage is helpful to confirm the diagnosis of alveolar haemorrhage. Pulmonary function tests are frequently altered, showing a reduction in the diffusion capacity for carbon monoxide, which can be associated with obstructive abnormalities related to airway stenosis. Nodular lung lesions tend to regress with immunosuppressive therapy, but lung disease may also require second line treatments such as plasmapheresis. In cases of massive diffuse alveolar haemorrhage, ventilator support is crucial in the management of the patient.
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Affiliation(s)
- Giovanni Filocamo
- Pediatric Rheumatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Commenda 9, 20122, Milan, Italy.
| | - Sofia Torreggiani
- grid.4708.bFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Carlo Agostoni
- grid.4708.bFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Susanna Esposito
- grid.9027.cPediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
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