1
|
Kurokawa M, Kurokawa R, Baba A, Gomi T, Cho S, Yoshioka K, Harada T, Kim J, Emile P, Abe O, Moritani T. Neuroimaging Features of Cytokine-related Diseases. Radiographics 2024; 44:e230069. [PMID: 38696321 DOI: 10.1148/rg.230069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
Cytokines are small secreted proteins that have specific effects on cellular interactions and are crucial for functioning of the immune system. Cytokines are involved in almost all diseases, but as microscopic chemical compounds they cannot be visualized at imaging for obvious reasons. Several imaging manifestations have been well recognized owing to the development of cytokine therapies such as those with bevacizumab (antibody against vascular endothelial growth factor) and chimeric antigen receptor (CAR) T cells and the establishment of new disease concepts such as interferonopathy and cytokine release syndrome. For example, immune effector cell-associated neurotoxicity is the second most common form of toxicity after CAR T-cell therapy toxicity, and imaging is recommended to evaluate the severity. The emergence of COVID-19, which causes a cytokine storm, has profoundly impacted neuroimaging. The central nervous system is one of the systems that is most susceptible to cytokine storms, which are induced by the positive feedback of inflammatory cytokines. Cytokine storms cause several neurologic complications, including acute infarction, acute leukoencephalopathy, and catastrophic hemorrhage, leading to devastating neurologic outcomes. Imaging can be used to detect these abnormalities and describe their severity, and it may help distinguish mimics such as metabolic encephalopathy and cerebrovascular disease. Familiarity with the neuroimaging abnormalities caused by cytokine storms is beneficial for diagnosing such diseases and subsequently planning and initiating early treatment strategies. The authors outline the neuroimaging features of cytokine-related diseases, focusing on cytokine storms, neuroinflammatory and neurodegenerative diseases, cytokine-related tumors, and cytokine-related therapies, and describe an approach to diagnosing cytokine-related disease processes and their differentials. ©RSNA, 2024 Supplemental material is available for this article.
Collapse
Affiliation(s)
- Mariko Kurokawa
- From the Department of Radiology, Division of Neuroradiology (M.K., R.K., A.B., T.G., S.C., K.Y., J.K., T.M.), and Department of Pathology (P.E.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan (M.K., R.K., S.C., K.Y., O.A.); Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan (A.B., T.G.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Ryo Kurokawa
- From the Department of Radiology, Division of Neuroradiology (M.K., R.K., A.B., T.G., S.C., K.Y., J.K., T.M.), and Department of Pathology (P.E.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan (M.K., R.K., S.C., K.Y., O.A.); Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan (A.B., T.G.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Akira Baba
- From the Department of Radiology, Division of Neuroradiology (M.K., R.K., A.B., T.G., S.C., K.Y., J.K., T.M.), and Department of Pathology (P.E.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan (M.K., R.K., S.C., K.Y., O.A.); Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan (A.B., T.G.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Taku Gomi
- From the Department of Radiology, Division of Neuroradiology (M.K., R.K., A.B., T.G., S.C., K.Y., J.K., T.M.), and Department of Pathology (P.E.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan (M.K., R.K., S.C., K.Y., O.A.); Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan (A.B., T.G.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Shinichi Cho
- From the Department of Radiology, Division of Neuroradiology (M.K., R.K., A.B., T.G., S.C., K.Y., J.K., T.M.), and Department of Pathology (P.E.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan (M.K., R.K., S.C., K.Y., O.A.); Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan (A.B., T.G.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Kyohei Yoshioka
- From the Department of Radiology, Division of Neuroradiology (M.K., R.K., A.B., T.G., S.C., K.Y., J.K., T.M.), and Department of Pathology (P.E.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan (M.K., R.K., S.C., K.Y., O.A.); Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan (A.B., T.G.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Taisuke Harada
- From the Department of Radiology, Division of Neuroradiology (M.K., R.K., A.B., T.G., S.C., K.Y., J.K., T.M.), and Department of Pathology (P.E.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan (M.K., R.K., S.C., K.Y., O.A.); Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan (A.B., T.G.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - John Kim
- From the Department of Radiology, Division of Neuroradiology (M.K., R.K., A.B., T.G., S.C., K.Y., J.K., T.M.), and Department of Pathology (P.E.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan (M.K., R.K., S.C., K.Y., O.A.); Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan (A.B., T.G.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Pinarbasi Emile
- From the Department of Radiology, Division of Neuroradiology (M.K., R.K., A.B., T.G., S.C., K.Y., J.K., T.M.), and Department of Pathology (P.E.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan (M.K., R.K., S.C., K.Y., O.A.); Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan (A.B., T.G.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Osamu Abe
- From the Department of Radiology, Division of Neuroradiology (M.K., R.K., A.B., T.G., S.C., K.Y., J.K., T.M.), and Department of Pathology (P.E.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan (M.K., R.K., S.C., K.Y., O.A.); Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan (A.B., T.G.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| | - Toshio Moritani
- From the Department of Radiology, Division of Neuroradiology (M.K., R.K., A.B., T.G., S.C., K.Y., J.K., T.M.), and Department of Pathology (P.E.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan (M.K., R.K., S.C., K.Y., O.A.); Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan (A.B., T.G.); and Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan (T.H.)
| |
Collapse
|
2
|
Lee BJ, Arter Z, Doh J, Griffin SP, Vittayawacharin P, Atallah S, Shieh KR, Tran M, Jodele S, Kongtim P, Ciurea SO. Eculizumab for Shiga-toxin-induced hemolytic uremic syndrome in adults with neurological involvement. EJHAEM 2024; 5:548-553. [PMID: 38895057 PMCID: PMC11182416 DOI: 10.1002/jha2.902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 06/21/2024]
Abstract
The role of eculizumab in treating Shiga-toxin-producing Escherichia coli (STEC) hemolytic uremic syndrome (HUS) patients with neurological involvement remains unclear. We describe two distinctly different STEC-HUS patients with neurologic involvement successfully managed with eculizumab, and perform a literature review of all published cases. Both patients had complete resolution of neurological symptoms after initiation of eculizumab. Eighty patients with STEC-HUS treated with eculizumab were identified in the literature, 68.7% had complete resolution of neurological symptoms. Based on our experience and literature review, three prevailing themes were noted: 1) Early eculizumab administration optimized neurological outcomes, 2) Symptom resolution may not be immediate, neurological symptoms may initially worsen before improvement, and 3) Plasma exchange yielded no benefit. Early administration of eculizumab may reverse neurotoxicity in patients with STEC-HUS.
Collapse
Affiliation(s)
- Benjamin J. Lee
- Department of PharmacyUniversity of California Irvine HealthOrangeCaliforniaUSA
- Department of Clinical Pharmacy PracticeSchool of Pharmacy and Pharmaceutical SciencesUniversity of CaliforniaIrvineCaliforniaUSA
| | - Zhaohui Arter
- Department of MedicineDivision of Hematology‐OncologyChao Family Comprehensive Cancer CenterUniversity of California Irvine HealthOrangeCaliforniaUSA
| | - Jean Doh
- Department of PharmacyUniversity of California Irvine HealthOrangeCaliforniaUSA
| | - Shawn P. Griffin
- Department of PharmacyUniversity of California Irvine HealthOrangeCaliforniaUSA
- Department of Clinical Pharmacy PracticeSchool of Pharmacy and Pharmaceutical SciencesUniversity of CaliforniaIrvineCaliforniaUSA
| | - Pongthep Vittayawacharin
- Department of MedicineDivision of Hematology‐OncologyChao Family Comprehensive Cancer CenterUniversity of California Irvine HealthOrangeCaliforniaUSA
- Division of HematologyDepartment of MedicineFaculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Steven Atallah
- Department of PharmacyUniversity of California Irvine HealthOrangeCaliforniaUSA
- Department of Clinical Pharmacy PracticeSchool of Pharmacy and Pharmaceutical SciencesUniversity of CaliforniaIrvineCaliforniaUSA
| | - Kevin R. Shieh
- Department of MedicineDivision of Hematology‐OncologyChao Family Comprehensive Cancer CenterUniversity of California Irvine HealthOrangeCaliforniaUSA
| | - Minh‐Ha Tran
- Department of Pathology and Laboratory MedicineDivision of Transfusion MedicineUniversity of California Irvine HealthOrangeCaliforniaUSA
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and ImmuneDeficiencyCancer and Blood Disease InstituteCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Piyanuch Kongtim
- Department of MedicineDivision of Hematology‐OncologyChao Family Comprehensive Cancer CenterUniversity of California Irvine HealthOrangeCaliforniaUSA
| | - Stefan O. Ciurea
- Department of MedicineDivision of Hematology‐OncologyChao Family Comprehensive Cancer CenterUniversity of California Irvine HealthOrangeCaliforniaUSA
| |
Collapse
|
3
|
Giordano M, Iacoviello O, Santangelo L, Martino M, Torres D, Carbone V, Scavia G, Loconsole D, Chironna M, Cristofori F, Francavilla R. Gastrointestinal involvement in STEC-associated hemolytic uremic syndrome: 10 years in a pediatric center. Pediatr Nephrol 2024; 39:1885-1891. [PMID: 38189960 PMCID: PMC11026196 DOI: 10.1007/s00467-023-06258-5] [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: 04/25/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND The gastrointestinal (GI) tract represents one of the main targets of typical hemolytic uremic syndrome (HUS) in children. In this observational study, we tried to establish (1) the main features of GI complications during STEC-HUS and (2) the relationship between Escherichia coli serotypes and Shiga toxin (Stx) variants with hepatopancreatic involvement. METHODS A total of 79 STEC-HUS patients were admitted to our pediatric nephrology department between January 2012 and June 2021. Evidence of intestinal, hepatobiliary, and pancreatic involvements was reported for each patient, alongside demographic, clinical, and laboratory features. Frequency of gastrointestinal complications across groups of patients infected by specific E. coli serotypes and Stx gene variants was evaluated. RESULTS Six patients developed a bowel complication: two developed rectal prolapse, and four developed bowel perforation which resulted in death for three of them and in bowel stenosis in one patient. Acute pancreatitis was diagnosed in 13 patients. An isolated increase in pancreatic enzymes and/or liver transaminases was observed in 41 and 15 patients, respectively. Biliary sludge was detected in three, cholelithiasis in one. Forty-seven patients developed direct hyperbilirubinemia. Neither E. coli serotypes nor Shiga toxin variants correlated with hepatic or pancreatic involvement. CONCLUSIONS During STEC-HUS, GI complications are common, ranging from self-limited elevation of laboratory markers to bowel perforation, a severe complication with a relevant impact on morbidity and mortality. Hepatopancreatic involvement is frequent, but usually short-lasting and self-limiting.
Collapse
Affiliation(s)
- Mario Giordano
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital Giovanni XXIII - AOU Consorziale Policlinico, Bari, Italy.
| | - Onofrio Iacoviello
- Interdisciplinary Department of Medicine, Pediatric Section, University of Bari "Aldo Moro, " Pediatric Hospital Giovanni XXIII, Bari, Italy
| | - Luisa Santangelo
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital Giovanni XXIII - AOU Consorziale Policlinico, Bari, Italy
| | - Marida Martino
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital Giovanni XXIII - AOU Consorziale Policlinico, Bari, Italy
| | - Diletta Torres
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital Giovanni XXIII - AOU Consorziale Policlinico, Bari, Italy
| | - Vincenza Carbone
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital Giovanni XXIII - AOU Consorziale Policlinico, Bari, Italy
| | - Gaia Scavia
- Department of Food Safety, Nutrition and Veterinary Public Health, Istituto Superiore Di Sanità, Rome, Italy
| | - Daniela Loconsole
- Department of Biomedical Sciences and Human Oncology, Hygiene Section, University of Bari "Aldo Moro", Bari, Italy
| | - Maria Chironna
- Department of Biomedical Sciences and Human Oncology, Hygiene Section, University of Bari "Aldo Moro", Bari, Italy
| | - Fernanda Cristofori
- Interdisciplinary Department of Medicine, Pediatric Section, University of Bari "Aldo Moro, " Pediatric Hospital Giovanni XXIII, Bari, Italy
| | - Ruggiero Francavilla
- Interdisciplinary Department of Medicine, Pediatric Section, University of Bari "Aldo Moro, " Pediatric Hospital Giovanni XXIII, Bari, Italy
| |
Collapse
|
4
|
Holland E, Koskay G, Chu T, Tauseef A, Nahas J, Andukuri V. Enterohemorrhagic Escherichia coli: trigger for small vessel vasculitis. Proc AMIA Symp 2024; 37:655-658. [PMID: 38910806 PMCID: PMC11188798 DOI: 10.1080/08998280.2024.2345555] [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: 02/29/2024] [Accepted: 03/22/2024] [Indexed: 06/25/2024] Open
Abstract
We describe the case of a 19-year-old woman who presented with abdominal pain, vomiting, and a palpable purpuric rash. The patient subsequently developed dysentery and was found to have an infection from Shiga toxin-producing Escherichia coli. The patient also met diagnostic criteria for IgA vasculitis (also known as Henoch Schönlein purpura) but had negative immunofluorescence biopsies of the rash. The patient was treated with steroids and achieved recovery. To our knowledge, this is the first documented case of IgA vasculitis in the setting of an enterohemorrhagic E. coli infection. This case highlights an atypical presentation of IgA vasculitis and the need to include small vessel vasculitis as a differential diagnosis when treating patients of all ages.
Collapse
Affiliation(s)
- Eva Holland
- School of Medicine, Creighton University, Omaha, Nebraska, USA
| | - Grant Koskay
- School of Medicine, Creighton University, Omaha, Nebraska, USA
| | - Tiffany Chu
- School of Medicine, Creighton University, Omaha, Nebraska, USA
| | - Abubakar Tauseef
- Department of Internal Medicine, Creighton University, Omaha, Nebraska, USA
| | - Joseph Nahas
- Department of Internal Medicine, Creighton University, Omaha, Nebraska, USA
| | - Venkata Andukuri
- Department of Internal Medicine, Creighton University, Omaha, Nebraska, USA
| |
Collapse
|
5
|
Che M, Moran SM, Smith RJ, Ren KYM, Smith GN, Shamseddin MK, Avila-Casado C, Garland JS. A case-based narrative review of pregnancy-associated atypical hemolytic uremic syndrome/complement-mediated thrombotic microangiopathy. Kidney Int 2024; 105:960-970. [PMID: 38408703 DOI: 10.1016/j.kint.2023.12.021] [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: 06/30/2023] [Revised: 12/07/2023] [Accepted: 12/14/2023] [Indexed: 02/28/2024]
Abstract
Atypical hemolytic uremic syndrome is a complement-mediated thrombotic microangiopathy caused by uncontrolled activation of the alternative complement pathway in the setting of autoantibodies to or rare pathogenic genetic variants in complement proteins. Pregnancy may serve as a trigger and unmask atypical hemolytic uremic syndrome/complement-mediated thrombotic microangiopathy (aHUS/CM-TMA), which has severe, life-threatening consequences. It can be difficult to diagnose aHUS/CM-TMA in pregnancy due to overlapping clinical features with other thrombotic microangiopathy syndromes including hypertensive disorders of pregnancy. However, the distinction among thrombotic microangiopathy etiologies in pregnancy is important because each syndrome has specific disease management and treatment. In this narrative review, we discuss 2 cases to illustrate the diagnostic challenges and evolving approach in the management of pregnancy-associated aHUS/CM-TMA. The first case involves a 30-year-old woman presenting in the first trimester who was diagnosed with aHUS/CM-TMA and treated with eculizumab from 19 weeks' gestation. Genetic testing revealed a likely pathogenic variant in CFI. She successfully delivered a healthy infant at 30 weeks' gestation. In the second case, a 22-year-old woman developed severe postpartum HELLP syndrome, requiring hemodialysis. Her condition improved with supportive management, yet investigations assessing for aHUS/CM-TMA remained abnormal 6 months postpartum consistent with persistent complement activation but negative genetic testing. Through detailed case discussion describing tests assessing for placental health, fetal anatomy, complement activation, autoantibodies to complement regulatory proteins, and genetic testing for aHUS/CM-TMA, we describe how these results aided in the clinical diagnosis of pregnancy-associated aHUS/CM-TMA and assisted in guiding patient management, including the use of anticomplement therapy.
Collapse
Affiliation(s)
- Michael Che
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah M Moran
- Department of Nephrology, Cork University, Cork, Ireland
| | - Richard J Smith
- University of Iowa Molecular Otolaryngology and Renal Research Laboratories, Iowa City, Iowa, USA
| | - Kevin Y M Ren
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Graeme N Smith
- Department of Obstetrics and Gynecology, Queen's University, Kingston, Ontario, Canada
| | - M Khaled Shamseddin
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Carmen Avila-Casado
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jocelyn S Garland
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada.
| |
Collapse
|
6
|
Tomeh R, Nemati A, Hashemi Tabar G, Tozzoli R, Badouei MA. Antimicrobial resistance, β-lactamase genotypes, and plasmid replicon types of Shiga toxin-producing Escherichia coli isolated from different animal hosts. J Appl Microbiol 2024; 135:lxae059. [PMID: 38467395 DOI: 10.1093/jambio/lxae059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/11/2024] [Accepted: 03/10/2024] [Indexed: 03/13/2024]
Abstract
AIMS The primary objective of this study was to analyze antimicrobial resistance (AMR), with a particular focus on β-lactamase genotypes and plasmid replicon types of Shiga toxin-producing Escherichia coli (STEC) strains originating from various animal hosts. METHODS AND RESULTS A total of 84 STEC strains were isolated from cattle (n = 32), sheep/goats (n = 26), pigeons (n = 20), and wild animals (n = 6) between 2010 and 2018 in various regions of Iran. The Kirby-Bauer susceptibility test and multiple polymerase chain reaction (PCR) panels were employed to elucidate the correlation between AMR and plasmid replicon types in STEC isolates. The predominant replicon types were IncFIC and IncFIB in cattle (46.8%), IncFIC in sheep/goats (46.1%), IncA/C in pigeons (90%), and IncP in wild animals (50%). STEC of serogroups O113, O26, and O111 harbored the IncFIB (100%), IncI1 (80%), and IncFIC + IncA/C (100%) plasmids, respectively. A remarkable AMR association was found between ciprofloxacin (100%), neomycin (68.7%), and tetracycline (61.7%) resistance with IncFIC; amoxicillin + clavulanic acid (88.8%) and tetracycline (61.7%) with IncA/C; ciprofloxacin (100%) with IncFIB; fosfomycin (85.7%) and sulfamethoxazole + trimethoprim (80%) with IncI1. IncI1 appeared in 83.3%, 50%, and 100% of the isolates harboring blaCTX-M, blaTEM, and blaOXA β-lactamase genes, respectively. CONCLUSIONS The emergence of O26/IncI1/blaCTX-M STEC in cattle farms poses a potential risk to public health.
Collapse
Affiliation(s)
- Rwida Tomeh
- Department of Pathobiology, Faculty of Veterinary Medicine, Ferdowsi University of Mashhad, Mashhad 9177948974, Iran
| | - Ali Nemati
- Department of Pathobiology, Faculty of Veterinary Medicine, Ferdowsi University of Mashhad, Mashhad 9177948974, Iran
| | - Gholamreza Hashemi Tabar
- Department of Pathobiology, Faculty of Veterinary Medicine, Ferdowsi University of Mashhad, Mashhad 9177948974, Iran
| | - Rosangela Tozzoli
- European Union Reference Laboratory for Escherichia coli, Department of Veterinary Public Health and Food Safety, Istituto Superiore di Sanità, Rome 00161, Italy
| | - Mahdi Askari Badouei
- Department of Pathobiology, Faculty of Veterinary Medicine, Ferdowsi University of Mashhad, Mashhad 9177948974, Iran
| |
Collapse
|
7
|
Pandey S, Shrivastava A, Harville YI, Cottler-Fox M, Harville TO. HLA-DR-DQ associations, combined with PLASMIC score, are reliable predictors of acquired thrombotic thrombocytopenic purpura (aTTP) and aid in differentiating aTTP from other thrombotic microangiopathies. Hematol Transfus Cell Ther 2024:S2531-1379(24)00012-9. [PMID: 38631980 DOI: 10.1016/j.htct.2023.11.016] [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: 07/26/2023] [Revised: 11/19/2023] [Accepted: 11/29/2023] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Thrombotic microangiopathies (TMA) are a group of disorders with overlapping clinical features that require urgent intervention. Treatment is based on the recognition of the TMA type, which is often challenging. The aim of this study was to identify specific HLA associations with different TMA types to aid rapid diagnosis and appropriate treatment, since the HLA assay can be completed within five hours. METHODS All 86 consecutive patients who presented to the University of Arkansas for Medical Sciences between May 2013 and January 2021 with a presumptive diagnosis of TMA were included in this study. HLA typing was performed and correlated with other clinical and laboratory studies. RESULTS In comparison with other types of TMA, patients with acquired thrombotic thrombocytopenic purpura (aTTP) showed increased frequencies of HLA-DRB1*11, HLA-DQB1*03:01/19, HLA-DRB1*08 and HLA-DRB3. Combining the presence of these HLA associations with a PLASMIC score of 6 or more achieved a higher positive predictive value (90%) for identifying aTTP than the PLASMIC score alone (69%). In comparison with other TMA types, patients with aTTP showed decreased frequencies of HLA-DRB4, HLA-DRB1*07, HLA-DQB1*02. The HLA-DRB1*07/DQB1*02 was not observed in any aTTP patients (negative predictive value: 100%), and thus the presence of this haplotype essentially rules out aTTP. Further, HLA-DRB1*11/DQB1*03:01/19 was absent in atypical hemolytic uremic syndrome patients. CONCLUSION HLA alleles can be used as an adjunct for the rapid assessment of TMA and can help to differentiate it from other primary and secondary forms of TMA, allowing for earlier definitive therapy.
Collapse
Affiliation(s)
- Soumya Pandey
- University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | | | | | | | - Terry O Harville
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| |
Collapse
|
8
|
Wildes DM, Harvey S, Costigan CS, Sweeney C, Twomey É, Awan A, Gorman KM. Eculizumab in STEC-HUS: a paradigm shift in the management of pediatric patients with neurological involvement. Pediatr Nephrol 2024; 39:315-324. [PMID: 37491519 DOI: 10.1007/s00467-023-06102-w] [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: 05/03/2023] [Revised: 06/27/2023] [Accepted: 07/17/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Eculizumab for the treatment of atypical hemolytic uremic syndrome (HUS) is a standard of care. Central nervous system (CNS) involvement in Shiga toxin-producing Escherichia coli (STEC)-HUS is associated with increased morbidity and mortality. There is no consensus on the use of plasma exchange and/or eculizumab. We report a series (n = 4) of children with CNS involvement in STEC-HUS with excellent outcomes after treatment with eculizumab only and supportive therapies. METHODS A retrospective chart review of patients with CNS involvement in STEC-HUS is managed with supportive therapies and eculizumab only. RESULTS Four patients (75% female) with a median age of 5 years and 11 months (IQR: 23.5-105.5 months) were admitted to a tertiary pediatric nephrology center with CNS involvement in STEC-HUS. Neurological symptoms presented between days 2 and 7 of illness and included ataxia, altered mental status, visual symptoms, and seizures. All had an abnormal MRI brain. All received two doses of eculizumab, 1 week apart (dosing according to weight). Resolution of neurological symptoms was evident at a mean of 60 h post-administration (range: 24-72 h). All patients have complete kidney and neurological recovery at 12-month follow-up. CONCLUSION We present a case series of four children with STEC-HUS and CNS involvement, managed with eculizumab only, in lieu of plasma exchange (as per our previous policy). The marked improvement in symptoms in our cohort supports the use of eculizumab, rather than plasma exchange in the CNS involvement of STEC-HUS.
Collapse
Affiliation(s)
- Dermot Michael Wildes
- Department of Paediatric Nephrology and Transplantation, Children's Health Ireland, Dublin, Ireland.
| | - Susan Harvey
- Department of Paediatric Neurology, Children's Health Ireland, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Caoimhe Suzanne Costigan
- Department of Paediatric Nephrology and Transplantation, Children's Health Ireland, Dublin, Ireland
| | - Clodagh Sweeney
- Department of Paediatric Nephrology and Transplantation, Children's Health Ireland, Dublin, Ireland
| | - Éilis Twomey
- Department of Paediatric Radiology, Children's Health Ireland, Dublin, Ireland
| | - Atif Awan
- Department of Paediatric Nephrology and Transplantation, Children's Health Ireland, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
- Department of Paediatrics and Child Health, Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, Ireland
| | - Kathleen Mary Gorman
- Department of Paediatric Neurology, Children's Health Ireland, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| |
Collapse
|
9
|
Durak C, Sahin EG, Yusuf Can Y, Varol F, Cam H. Why has plasma exchange failed in TRACK syndrome? Lessons from a new variant of the atypical hemolytic uremic syndrome. J Clin Apher 2023; 38:647-650. [PMID: 37338178 DOI: 10.1002/jca.22070] [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: 04/11/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/21/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare and life-threatening form of thrombotic microangiopathy, associated with high mortality and morbidity. Most cases present with hemolytic anemia, thrombocytopenia, and renal insufficiency. However, it can have unusual multiple end-organ injuries including extrarenal organ and system involvements such as neurologic, cardiac, gastrointestinal, and respiratory systems. We describe a 4-year-old girl who developed aHUS due to the TSEN2 mutation and had cardiac involvement. She did not benefit from plasma exchange, as stated in previous cases. It should be kept in mind that therapeutic plasma exchange may not be beneficial in some cases of aHUS, especially due to genetic mutations.
Collapse
Affiliation(s)
- Cansu Durak
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Ebru Guney Sahin
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Yasar Yusuf Can
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Fatih Varol
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Halit Cam
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| |
Collapse
|
10
|
Hambrick HR, Short K, Askenazi D, Krallman K, Pino C, Yessayan L, Westover A, Humes HD, Goldstein SL. Hemolytic Uremic Syndrome-Induced Acute Kidney Injury Treated via Immunomodulation with the Selective Cytopheretic Device. Blood Purif 2023; 52:812-820. [PMID: 37607519 DOI: 10.1159/000531963] [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: 02/24/2023] [Accepted: 07/05/2023] [Indexed: 08/24/2023]
Abstract
INTRODUCTION Shiga-toxin associated-hemolytic uremic syndrome (STEC-HUS) is a severe cause of acute kidney injury (AKI) in children. Although most children recover, about 5% die and 30% develop chronic renal morbidity. HUS pathophysiology includes activated neutrophils damaging vascular endothelial cells. Therapeutic immunomodulation of activated neutrophils may alter the progression of disease. We present 3 pediatric patients treated with the selective cytopheretic device (SCD). METHODS We describe a 12 y.o. (patient 1) and two 2 y.o. twins (patients 2 and 3) with STEC-HUS requiring continuous renal replacement therapy (CRRT) who were enrolled in two separate studies of the SCD. RESULTS Patient 1 presented with STEC-HUS causing AKI and multisystem organ failure and received 7 days of SCD and CRRT treatment. After SCD initiation, the patient had gradual recovery of multi-organ dysfunction, with normal kidney and hematologic parameters at 60-day follow-up. Patients 2 and 3 presented with STEC-HUS with AKI requiring dialysis. Each received 24 h of SCD therapy. Thereafter, both gradually improved, with normalization (patient 2) and near-normalization (patient 3) of kidney function at 60-day follow-up. CONCLUSION Immunomodulatory treatment with the SCD was associated with improvements in multisystem stigmata of STEC-HUS-induced AKI and was well-tolerated without any device-related adverse events.
Collapse
Affiliation(s)
- H Rhodes Hambrick
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kara Short
- Pediatric and Infant Center for Acute Nephrology, Children's of Alabama, Birmingham, Alabama, USA
| | - David Askenazi
- Pediatric and Infant Center for Acute Nephrology, Children's of Alabama, Birmingham, Alabama, USA
| | - Kelli Krallman
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher Pino
- Division of Nephrology, University of Michigan Department of Medicine, Ann Arbor, Michigan, USA
- Innovative BioTherapies Inc., Ann Arbor, Michigan, USA
| | - Lenar Yessayan
- Division of Nephrology, University of Michigan Department of Medicine, Ann Arbor, Michigan, USA
- Innovative BioTherapies Inc., Ann Arbor, Michigan, USA
| | - Angela Westover
- Division of Nephrology, University of Michigan Department of Medicine, Ann Arbor, Michigan, USA
- Innovative BioTherapies Inc., Ann Arbor, Michigan, USA
| | - H David Humes
- Division of Nephrology, University of Michigan Department of Medicine, Ann Arbor, Michigan, USA
- Innovative BioTherapies Inc., Ann Arbor, Michigan, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
11
|
Kirsanova TV, Balakireva AI, Fedorova TA, Pyregov AV, Rogachevskiy OV. [Various phenotypes of postpartum atypical hemolytic uremic syndrome: the role of genetic testing in determining prognosis. Case report]. TERAPEVT ARKH 2023; 95:511-515. [PMID: 38158972 DOI: 10.26442/00403660.2023.06.202233] [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: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 01/03/2024]
Abstract
We report a case of atypical hemolytic uremic syndrome (aHUS) that occurred after childbirth in a patient with a history of numerous recurrent episodes of TMA with nephrotic proteinuria and impaired renal function. At 33 weeks of the first spontaneous pregnancy, proteinuria up to 0.8 g/l was first registered, at 38 weeks she was hospitalized with proteinuria, reaching a maximum of 13 g/l, she was delivered promptly, after which progressive thrombocytopenia was noted over the next few days (up to 44×109/l) and anemia and severe arterial hypertension, which could not be corrected by several groups of antihypertensive drugs. Initiated plasma therapy had no effect. After exclusion of all other causes of TMA, therapy with eculizumab was initiated, which made it possible to quickly and completely stop the phenomena of TMA. The presented observation demonstrates the successful treatment of recurrent course of aHUS with eculizumab with the achievement of complete recovery of kidney function in a patient with a homozygous mutation in the MCP gene. It is worth noting the importance of genetic research even in those situations where clinically aHUS is beyond doubt.
Collapse
Affiliation(s)
- T V Kirsanova
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | | | - T A Fedorova
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | - A V Pyregov
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | - O V Rogachevskiy
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| |
Collapse
|
12
|
Holers VM. Complement therapeutics are coming of age in rheumatology. Nat Rev Rheumatol 2023; 19:470-485. [PMID: 37337038 DOI: 10.1038/s41584-023-00981-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/21/2023]
Abstract
The complement system was described over 100 years ago, and it is well established that activation of this pathway accompanies the great majority of autoimmune and inflammatory diseases. In addition, over three decades of work in murine models of human disease have nearly universally demonstrated that complement activation is upstream of tissue injury and the engagement of pro-inflammatory mechanisms such as the elaboration of cytokines and chemokines, as well as myeloid cell recruitment and activation. With that background, and taking advantage of advances in the development of biologic and small-molecule therapeutics, the creation and clinical evaluation of complement therapeutics is now rapidly expanding. This article reviews the current state of the complement therapeutics field, with a focus on their use in diseases cared for or consulted upon by rheumatologists. Included is an overview of the activation mechanisms and components of the system, in addition to the mechanisms by which the complement system interacts with other immune system constituents. The various therapeutic approaches to modulating the system in rheumatic and autoimmune diseases are reviewed. To understand how best to clinically assess the complement system, methods of its evaluation are described. Finally, next-generation therapeutic and diagnostic advances that can be envisioned for the future are discussed.
Collapse
Affiliation(s)
- V Michael Holers
- Medicine/Rheumatology, University of Colorado School of Medicine, Aurora, CO, USA.
| |
Collapse
|
13
|
Ghoshal S. Renal and Electrolyte Disorders and the Nervous System. Continuum (Minneap Minn) 2023; 29:797-825. [PMID: 37341331 DOI: 10.1212/con.0000000000001286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE Neurologic complications are a major contributor to death and disability in patients with renal disease. Oxidative stress, endothelial dysfunction, accelerated arteriosclerosis, and uremic inflammatory milieu affect both the central and peripheral nervous systems. This article reviews the unique contributions of renal impairment to neurologic disorders and their common clinical manifestations as the prevalence of renal disease increases in a globally aging population. LATEST DEVELOPMENT Advances in the understanding of the pathophysiologic interplay between the kidneys and brain, also referred to as the kidney-brain axis, have led to more widespread recognition of associated changes in neurovascular dynamics, central nervous system acidification, and uremia-associated endothelial dysfunction and inflammation in the central and peripheral nervous systems. Acute kidney injury increases mortality in acute brain injury to nearly 5 times that seen in matched controls. Renal impairment and its associated increased risks of intracerebral hemorrhage and accelerated cognitive decline are developing fields. Dialysis-associated neurovascular injury is increasingly recognized in both continuous and intermittent forms of renal replacement therapy, and treatment strategies for its prevention are evolving. ESSENTIAL POINTS This article summarizes the effects of renal impairment on the central and peripheral nervous systems with special considerations in acute kidney injury, patients requiring dialysis, and conditions that affect both the renal and nervous systems.
Collapse
|
14
|
Colello R, Baigorri M, Del Canto F, González J, Rogé A, van der Ploeg C, Sánchez Chopa F, Sparo M, Etcheverría A, Padola NL. Occurrence and genetic characterization of Shiga toxin-producing Escherichia coli on bovine and pork carcasses and the environment from transport trucks. World J Microbiol Biotechnol 2023; 39:174. [PMID: 37115263 DOI: 10.1007/s11274-023-03624-1] [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: 02/08/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023]
Abstract
Shiga toxin-producing Escherichia coli (STEC) are foodborne pathogens causing severe diseases. The ability of STEC to produce disease is associated with Shiga toxin (Stx) production. We investigated the occurrence of STEC on bovine and pork carcasses and walls of trucks where they were transported, and we characterized virulence genes and serotypes of STEC strains. We compared the whole genomic sequencing of a STEC O157:H7 strain isolated from a bovine carcass in this work and a STEC O157:H7 strain isolated from a child with HUS, both isolated in 2019. We studied the relationship between these isolates and others collected in the database. The results show a 40% of STEC and two different serogroups were identified (O130 and O157). STEC O157:H7 were isolated from bovine carcasses and harbored stx2, eae, ehxA, katP, espP, stcE, ECSP_0242/1773/2687/2870/2872/3286/3620 and were classified as lineage I/II. In STEC non-O157 isolates, three isolates were isolated from bovine carcasses and harbored the serogroup O130 and one strain isolated from pork carcasses was O-non-typeable. All STEC non-O157 harbored sxt1 gene. The analysis from the whole genome showed that both STEC O157:H7 strains belonged to the hypervirulent clade 8, ST11, phylogroup E, carried the allele tir 255 T > A T, and they were not clonal. The analysis of information allows us to conclude that the STEC strains circulate in pork and bovine carcasses arriving in transport. This situation represents a risk for the consumers and the need to implement an integrated STEC control in the food chain.
Collapse
Affiliation(s)
- Rocío Colello
- Facultad de Ciencias Veterinarias, Universidad Nacional del Centro de la Provincia de Buenos Aires (UNCPBA), Tandil, Buenos Aires, Argentina.
- Centro de Investigación Veterinaria de Tandil (CIVETAN), UNCPBA- CICPBA- CONICET, Tandil, Buenos Aires, Argentina.
| | - Manuela Baigorri
- Facultad de Ciencias Veterinarias, Universidad Nacional del Centro de la Provincia de Buenos Aires (UNCPBA), Tandil, Buenos Aires, Argentina
| | - Felipe Del Canto
- Programa de Microbiología y Micología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Juliana González
- Facultad de Ciencias Veterinarias, Universidad Nacional del Centro de la Provincia de Buenos Aires (UNCPBA), Tandil, Buenos Aires, Argentina
- Centro de Investigación Veterinaria de Tandil (CIVETAN), UNCPBA- CICPBA- CONICET, Tandil, Buenos Aires, Argentina
| | - Ariel Rogé
- Servicio Antígenos y Antisueros, Instituto Nacional de Producción de Biológicos, Administración Nacional de Laboratorios e Institutos de Salud "Dr. Carlos G. Malbrán", Buenos Aires, Argentina
| | - Claudia van der Ploeg
- Servicio Antígenos y Antisueros, Instituto Nacional de Producción de Biológicos, Administración Nacional de Laboratorios e Institutos de Salud "Dr. Carlos G. Malbrán", Buenos Aires, Argentina
| | - Federico Sánchez Chopa
- Facultad de Ciencias Veterinarias, Universidad Nacional del Centro de la Provincia de Buenos Aires (UNCPBA), Tandil, Buenos Aires, Argentina
- Centro de Investigación Veterinaria de Tandil (CIVETAN), UNCPBA- CICPBA- CONICET, Tandil, Buenos Aires, Argentina
| | - Mónica Sparo
- Laboratorio de Microbiología Clínica, Hospital Ramón Santamarina, Tandil, Buenos Aires, Argentina
| | - Analía Etcheverría
- Facultad de Ciencias Veterinarias, Universidad Nacional del Centro de la Provincia de Buenos Aires (UNCPBA), Tandil, Buenos Aires, Argentina
- Centro de Investigación Veterinaria de Tandil (CIVETAN), UNCPBA- CICPBA- CONICET, Tandil, Buenos Aires, Argentina
| | - Nora Lía Padola
- Facultad de Ciencias Veterinarias, Universidad Nacional del Centro de la Provincia de Buenos Aires (UNCPBA), Tandil, Buenos Aires, Argentina
- Centro de Investigación Veterinaria de Tandil (CIVETAN), UNCPBA- CICPBA- CONICET, Tandil, Buenos Aires, Argentina
| |
Collapse
|
15
|
Piras R, Valoti E, Alberti M, Bresin E, Mele C, Breno M, Liguori L, Donadelli R, Rigoldi M, Benigni A, Remuzzi G, Noris M. CFH and CFHR structural variants in atypical Hemolytic Uremic Syndrome: Prevalence, genomic characterization and impact on outcome. Front Immunol 2023; 13:1011580. [PMID: 36793547 PMCID: PMC9923232 DOI: 10.3389/fimmu.2022.1011580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/28/2022] [Indexed: 01/31/2023] Open
Abstract
Introduction Atypical hemolytic uremic syndrome (aHUS) is a rare disease that manifests with microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure, and is associated with dysregulation of the alternative complement pathway. The chromosomal region including CFH and CFHR1-5 is rich in repeated sequences, favoring genomic rearrangements that have been reported in several patients with aHUS. However, there are limited data on the prevalence of uncommon CFH-CFHR genomic rearrangements in aHUS and their impact on disease onset and outcomes. Methods In this study, we report the results of CFH-CFHR Copy Number Variation (CNV) analysis and the characterization of resulting structural variants (SVs) in a large cohort of patients, including 258 patients with primary aHUS and 92 with secondary forms. Results We found uncommon SVs in 8% of patients with primary aHUS: 70% carried rearrangements involving CFH alone or CFH and CFHR (group A; n=14), while 30% exhibited rearrangements including only CFHRs (group B; n=6). In group A, 6 patients presented CFH::CFHR1 hybrid genes, 7 patients carried duplications in the CFH-CFHR region that resulted either in the substitution of the last CFHR1 exon(s) with those of CFH (CFHR1::CFH reverse hybrid gene) or in an internal CFH duplication. In group A, the large majority of aHUS acute episodes not treated with eculizumab (12/13) resulted in chronic ESRD; in contrast, anti-complement therapy induced remission in 4/4 acute episodes. aHUS relapse occurred in 6/7 grafts without eculizumab prophylaxis and in 0/3 grafts with eculizumab prophylaxis. In group B, 5 subjects had the CFHR31-5::CFHR410 hybrid gene and one had 4 copies of CFHR1 and CFHR4. Compared with group A, patients in group B exhibited a higher prevalence of additional complement abnormalities and earlier disease onset. However, 4/6 patients in this group underwent complete remission without eculizumab treatment. In secondary forms we identified uncommon SVs in 2 out of 92 patients: the CFHR31-5::CFHR410 hybrid and a new internal duplication of CFH. Discussion In conclusion, these data highlight that uncommon CFH-CFHR SVs are frequent in primary aHUS and quite rare in secondary forms. Notably, genomic rearrangements involving the CFH are associated with a poor prognosis but carriers respond to anti-complement therapy.
Collapse
|
16
|
Liu Y, Thaker H, Wang C, Xu Z, Dong M. Diagnosis and Treatment for Shiga Toxin-Producing Escherichia coli Associated Hemolytic Uremic Syndrome. Toxins (Basel) 2022; 15:10. [PMID: 36668830 PMCID: PMC9862836 DOI: 10.3390/toxins15010010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/13/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
Shiga toxin-producing Escherichia coli (STEC)-associated hemolytic uremic syndrome (STEC-HUS) is a clinical syndrome involving hemolytic anemia (with fragmented red blood cells), low levels of platelets in the blood (thrombocytopenia), and acute kidney injury (AKI). It is the major infectious cause of AKI in children. In severe cases, neurological complications and even death may occur. Treating STEC-HUS is challenging, as patients often already have organ injuries when they seek medical treatment. Early diagnosis is of great significance for improving prognosis and reducing mortality and sequelae. In this review, we first briefly summarize the diagnostics for STEC-HUS, including history taking, clinical manifestations, fecal and serological detection methods for STEC, and complement activation monitoring. We also summarize preventive and therapeutic strategies for STEC-HUS, such as vaccines, volume expansion, renal replacement therapy (RRT), antibiotics, plasma exchange, antibodies and inhibitors that interfere with receptor binding, and the intracellular trafficking of the Shiga toxin.
Collapse
Affiliation(s)
- Yang Liu
- Department of Nephrology, The First Hospital of Jilin University, Changchun 130021, China
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Microbiology, Harvard Medical School, Boston, MA 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Hatim Thaker
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Microbiology, Harvard Medical School, Boston, MA 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Chunyan Wang
- Department of Nephrology, Children’s Hospital of Fudan University, Shanghai 201102, China
| | - Zhonggao Xu
- Department of Nephrology, The First Hospital of Jilin University, Changchun 130021, China
| | - Min Dong
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Microbiology, Harvard Medical School, Boston, MA 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
17
|
Muacevic A, Adler JR, Abdulqader MA, Yolmo D, Shaikh M, Rupasinghe PCD, Patel AA. Trends and Outcomes of Hospitalizations Due to Hemolytic Uremic Syndrome: A National Perspective. Cureus 2022; 14:e32315. [PMID: 36628001 PMCID: PMC9825057 DOI: 10.7759/cureus.32315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) is a rare but challenging disease with varying degrees of mortality and prognosis. We aim to evaluate the trends and outcomes of hospitalizations due to HUS by utilizing a large population-based dataset. METHODS We derived a study cohort from the Nationwide Inpatient Sample (NIS) for the years 2007-2018. Our primary outcomes were in-hospital mortality, discharge disposition, and predictors of poor outcomes. We then utilized the Cochran Armitage trend test and multivariable survey logistic regression models to analyze the trends, outcomes, and predictors. RESULTS A total of 8043 hospitalizations ranging from age zero to above 65 years of age occurred due to HUS from 2007-2018. The number of hospitalizations with HUS increased steadily from 528 in 2007 to 800 in 2013, but afterwards, we noticed a steady decline to 620 in 2018. Additionally, trends of in-hospital mortality slowly increased over the study period but we noticed a decline in the rate of discharge to skilled nursing facilities (SNFs). Furthermore, in multivariable regression analysis, predictors of increased mortality in hospitalized HUS patients were advanced age (95%CI: 1.221-1.686; p-value <0.0001) and requirement for dialysis (95%CI: 1.141-4.167; p-value: <0.0001). Advanced age >65 years (OR: 2.599, 95%CI: 1.406-4.803; p-value: 0.0023), as well as comorbidities such as diabetes mellitus and pulmonary circulatory diseases, which are under vascular events (OR: 1.467, 95%CI:1.075-2.000; p-value: 0.0156), were shown to have a higher rate of discharge to SNFs. Moreover, patients needing intravenous immunoglobulin (IVIG) and plasmapheresis had high odds of discharge to SNFs ((OR: 1.99, 95%CI: 1.307-3.03; p-value: 0.0013) and (OR: 5.509, 95%CI: 2.807- 10.809; p-value <0.0001), respectively), as well as smaller hospital bed size and hospital type (OR: 1.849, 95%CI: 1.142-2.993; p-value: 0.012). CONCLUSION In this national representative study, we observed a total decrease in hospitalizations as well as discharge to SNFs; however we saw an increase in inpatient mortality. We also identified multiple predictors significantly associated with increased mortality, some of which are potentially modifiable and can be points of interest for future studies.
Collapse
|
18
|
Ijiri N, Sato M, Konoeda C, Nagayama K, Nakajima J. Basiliximab for early perioperative transplant-associated thrombotic microangiopathy after lung transplantation: a case report. Surg Case Rep 2022; 8:187. [PMID: 36173476 PMCID: PMC9522937 DOI: 10.1186/s40792-022-01539-x] [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: 07/23/2022] [Accepted: 09/20/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Thrombotic microangiopathy is a syndrome characterized by microangiopathic hemolytic anemia and platelet aggregation, which is caused by endothelial injury, microcirculation thrombosis, and fibrin deposition. Transplant-associated thrombotic microangiopathy rarely occurs after lung transplantation and the onset is generally later than that after bone marrow or other solid organ transplantation. The treatment is to stop administration of the causal agent, which is often a calcineurin inhibitor, such as tacrolimus and cyclosporine. We herein report the case of a patient with early post-transplant thrombotic microangiopathy after lung transplantation treated by introducing basiliximab and temporarily stopping any calcineurin inhibitors until resuming treatment with an alternative calcineurin inhibitor.
Case presentation
A 58-year-old Asian woman underwent bilateral lung transplantation for hypersensitivity pneumonitis caused by an avian antigen, or bird fancier’s lung disease. Postoperatively, she was started on triple immunosuppressive therapy, which included tacrolimus, mycophenolate mofetil, and steroids. On postoperative day 6, she developed thrombocytopenia followed by fever, hemolytic anemia, renal dysfunction, and purpura on her limbs and abdomen. She was diagnosed with transplant-associated thrombotic microangiopathy, and tacrolimus was thought to be the causal agent. We stopped tacrolimus and administered basiliximab. Then, she developed oliguria and needed continuous hemodiafiltration. On postoperative day 14, the platelet count recovered and she was switched from basiliximab to cyclosporine. Using this protocol, worsening thrombotic microangiopathy and acute rejection were avoided.
Conclusions
We report the case of a patient with early post-transplant thrombotic microangiopathy after lung transplantation that was treated with basiliximab. Switching from calcineurin inhibitors using basiliximab may be an option for treating thrombotic microangiopathy without increasing the risk of acute rejection.
Collapse
|
19
|
Abstract
PURPOSE OF REVIEW COVID-19 remains a major source of concern, particularly as new variants emerge and with recognition that patients may suffer long-term effects. Mechanisms underlying SARS-CoV-2 mediated organ damage and the associated vascular endotheliopathy remain poorly understood, hindering new drug development. Here, we highlight selected key concepts of how the complement system, a major component of innate immunity that is dysregulated in COVID-19, participates in the thromboinflammatory response and drives the vascular endotheliopathy. RECENT FINDINGS Recent studies have revealed mechanisms by which complement is activated directly by SARS-CoV-2, and how the system interfaces with other innate thromboinflammatory cellular and proteolytic pathways involving platelets, neutrophils, neutrophil extracellular traps and the coagulation and kallikrein-kinin systems. With this new information, multiple potential sites for therapeutic intervention are being uncovered and evaluated in the clinic. SUMMARY Infections with SARS-CoV-2 cause damage to the lung alveoli and microvascular endothelium via a process referred to as thromboinflammation. Although not alone in being dysregulated, complement is an early player, prominent in promoting the endotheliopathy and consequential organ damage, either directly and/or via the system's complex interplay with other cellular, molecular and biochemical pathways. Delineating these critical interactions is revealing novel and promising strategies for therapeutic intervention.
Collapse
Affiliation(s)
- Edward M Conway
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Edward L G Pryzdial
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, British Columbia, Canada
- Canadian Blood Services, Medical Affairs and Innovation, Ottawa, Ontario, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
20
|
Wood WD, Elmaghrabi A, Gotway G, Wolf MTF. The roles of homocysteinemia and methylmalonic acidemia in kidney injury in atypical hemolytic uremic syndrome caused by cobalamin C deficiency. Pediatr Nephrol 2022; 37:1415-1418. [PMID: 34854955 PMCID: PMC9160205 DOI: 10.1007/s00467-021-05372-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/01/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cobalamin C (cblC), a vitamin B12 processing protein, plays a crucial role in metabolism for the conversion of homocysteine to methionine and methylmalonyl-CoA to succinyl-CoA. CblC deficiency, an inborn error of cobalamin processing, is a rare cause of atypical hemolytic-uremic syndrome (aHUS) and results in hyperhomocysteinemia and methylmalonic aciduria. Both substances are thought to contribute to thrombotic microangiopathy (TMA) in cblC deficiency patients. However, the roles of homocysteine and methylmalonic acid (MMA) in these patients remain unclear. We want to shed more light on the contributions of homocysteine and MMA levels as contributing factors for thrombotic microangiopathy (TMA)/aHUS by a follow-up of a cblC deficiency patient over 6 years. CASE DIAGNOSIS A 27-day-old Hispanic female presented with abnormal C3-carnitine on her newborn screen, poor feeding, decreased activity, and oligouria. She was diagnosed with cblC deficiency after laboratory results revealed elevated serum homocysteine, and serum MMA along with genetic testing showing a homozygous pathogenic frameshift variant in MMACHC. The patient developed aHUS and acute kidney injury (AKI), which resolved after appropriate therapy. Over 6 years, she continued to have normal kidney function with no thrombocytopenia despite persistently elevated homocysteine and MMA levels. CONCLUSION We question the roles of homocysteine and MMA as causative of aHUS/TMA in cblC deficiency as they remained elevated during follow-up but did not result in aHUS/TMA or AKI. Hyperhomocysteinemia and/or MMA caused by other metabolic diseases do not result in aHUS/TMA or AKI. This suggests that other nephrotoxic factors may trigger aHUS/TMA in cblC patients.
Collapse
Affiliation(s)
- William D Wood
- Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ayah Elmaghrabi
- Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Garrett Gotway
- Pediatric Genetics and Metabolism, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthias T F Wolf
- Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| |
Collapse
|
21
|
Buelli S, Locatelli M, Carminati CE, Corna D, Cerullo D, Imberti B, Perico L, Brigotti M, Abbate M, Zoja C, Benigni A, Remuzzi G, Morigi M. Shiga Toxin 2 Triggers C3a-Dependent Glomerular and Tubular Injury through Mitochondrial Dysfunction in Hemolytic Uremic Syndrome. Cells 2022; 11:cells11111755. [PMID: 35681450 PMCID: PMC9179250 DOI: 10.3390/cells11111755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/13/2022] [Accepted: 05/23/2022] [Indexed: 11/16/2022] Open
Abstract
Shiga toxin (Stx)-producing Escherichia coli is the predominant offending agent of post-diarrheal hemolytic uremic syndrome (HUS), a rare disorder of microvascular thrombosis and acute kidney injury possibly leading to long-term renal sequelae. We previously showed that C3a has a critical role in the development of glomerular damage in experimental HUS. Based on the evidence that activation of C3a/C3a receptor (C3aR) signaling induces mitochondrial dysregulation and cell injury, here we investigated whether C3a caused podocyte and tubular injury through induction of mitochondrial dysfunction in a mouse model of HUS. Mice coinjected with Stx2/LPS exhibited glomerular podocyte and tubular C3 deposits and C3aR overexpression associated with cell damage, which were limited by C3aR antagonist treatment. C3a promoted renal injury by affecting mitochondrial wellness as demonstrated by data showing that C3aR blockade reduced mitochondrial ultrastructural abnormalities and preserved mitochondrial mass and energy production. In cultured podocytes and tubular cells, C3a caused altered mitochondrial fragmentation and distribution, and reduced anti-oxidant SOD2 activity. Stx2 potentiated the responsiveness of renal cells to the detrimental effects of C3a through increased C3aR protein expression. These results indicate that C3aR may represent a novel target in Stx-associated HUS for the preservation of renal cell integrity through the maintenance of mitochondrial function.
Collapse
Affiliation(s)
- Simona Buelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
- Correspondence: ; Tel.: +39-035-42131; Fax: +39-035-319-331
| | - Monica Locatelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Claudia Elisa Carminati
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Daniela Corna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Domenico Cerullo
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Barbara Imberti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Luca Perico
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Maurizio Brigotti
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, 40126 Bologna, Italy;
| | - Mauro Abbate
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Carlamaria Zoja
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Ariela Benigni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Marina Morigi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| |
Collapse
|
22
|
Riedl Khursigara M, Matsuda-Abedini M, Radhakrishnan S, Hladunewich MA, Lemaire M, Teoh CW, Noone D, Licht C. A Guide for Adult Nephrologists and Hematologists to Managing Atypical Hemolytic Uremic Syndrome and C3 Glomerulopathy in Teens Transitioning to Young Adults. Adv Chronic Kidney Dis 2022; 29:231-242. [PMID: 36084970 DOI: 10.1053/j.ackd.2022.04.003] [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: 03/12/2022] [Accepted: 04/11/2022] [Indexed: 11/11/2022]
Abstract
Atypical hemolytic uremic syndrome and C3 glomerulopathy/immune complex membranoproliferative glomerulonephritis are ultra-rare chronic, complement-mediated diseases with childhood manifestation in a majority of cases. Transition of clinical care of patients from pediatric to adult nephrologists-typically with controlled disease in native or transplant kidneys in case of atypical hemolytic uremic syndrome and often with chronic progressive disease despite treatment efforts in case of C3 glomerulopathy/immune complex membranoproliferative glomerulonephritis-identifies a challenging juncture in the journey of these patients. Raising awareness for the vulnerability of this patient cohort; providing education on disease pathophysiology and management including the use of new, high-precision complement antagonists; and establishing an ongoing dialog of patients, families, and all members of the health care team involved on either side of the age divide will be inevitable to ensure optimal patient outcomes and a safe transition of these patients to adulthood.
Collapse
Affiliation(s)
| | - Mina Matsuda-Abedini
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Seetha Radhakrishnan
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michelle A Hladunewich
- Division of Nephrology and Obstetric Medicine, Department of Medicine, Sunnybrook Health Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mathieu Lemaire
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Damien Noone
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.
| |
Collapse
|
23
|
Cagil Y, Tan S, Fadell M, Husain S, Ming Yeh A. The Risk of Colonic Strictures with Colitis Following Hemolytic Uremic Syndrome: A Case Report of a Toddler. JPGN REPORTS 2022; 3:e188. [PMID: 37168899 PMCID: PMC10158366 DOI: 10.1097/pg9.0000000000000188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 02/01/2022] [Indexed: 05/13/2023]
Abstract
Gastrointestinal manifestations of hemolytic uremic syndrome (HUS) are rare in pediatrics, but can have significant impact on the course of the disease. While various infectious etiologies are associated with HUS, Enterohemorrhagic Escherichia coli (EHEC) has been a focus of interest in its role in post-diarrheal HUS. We report a previously healthy 3-year-old boy who presented with bloody diarrhea, was found to be EHEC positive, and developed gastrointestinal complications of HUS including chronic colitis and strictures. The case illustrates that, though rare, HUS can have long-term gastrointestinal effects.
Collapse
Affiliation(s)
- Yasemin Cagil
- From the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Palo Alto, CA
| | - Serena Tan
- Department of Pediatric Pathology, Palo Alto, CA
| | - Michael Fadell
- Department of Pediatric Radiology, Lucile Packard Children’s Hospital, Stanford Children’s Health, Palo Alto, CA
| | - Sohail Husain
- From the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Palo Alto, CA
| | - Ann Ming Yeh
- From the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Palo Alto, CA
| |
Collapse
|
24
|
Formeck CL, Manrique-Caballero CL, Gómez H, Kellum JA. Uncommon Causes of Acute Kidney Injury. Crit Care Clin 2022; 38:317-347. [DOI: 10.1016/j.ccc.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
25
|
Feng J, Xu K, Shi X, Xu L, Liu L, Wang F, Zhong X, Liu G, Wang J, Gao P, Ding J, Wang S, Zhan S. Incidence and cost of haemolytic uraemic syndrome in urban China: a national population-based analysis. BMC Nephrol 2022; 23:122. [PMID: 35354386 PMCID: PMC8969241 DOI: 10.1186/s12882-022-02746-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background Haemolytic uraemic syndrome (HUS) is a severe syndrome that causes a substantial burden for patients and their families and is the leading cause of acute kidney injury in children. However, data on the epidemiology and disease burden of HUS in Asia, including China, are limited. We aimed to estimate the incidence and cost of HUS in China. Methods Data about HUS from 2012 to 2016 were extracted from the Urban Employee Basic Medical Insurance (UEBMI) and Urban Resident Basic Medical Insurance (URBMI) databases. All cases were identified by ICD code and Chinese diagnostic terms. The 2016 national incidence rates were estimated and stratified by sex, age and season. The associated medical costs were also calculated. Results The crude incidence of HUS was 0.66 per 100,000 person-years (95% CI: 0.35 to 1.06), and the standardized incidence was 0.57 (0.19 to 1.18). The incidence of HUS in males was slightly higher than that in females. The age group with the highest incidence of HUS was patients < 1 year old (5.08, 95% CI: 0.23 to 24.87), and the season with the highest incidence was autumn, followed by winter. The average cost of HUS was 2.15 thousand US dollars per patient, which was higher than the national average cost for all inpatients in the same period. Conclusions This is the first population-based study on the incidence of HUS in urban China. The age and seasonal distributions of HUS in urban China are different from those in most developed countries, suggesting a difference in aetiology. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02746-2.
Collapse
Affiliation(s)
- Jingnan Feng
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Haidian District, No.38, Xueyuan Rd, Beijing, China
| | - Ke Xu
- Department of Pediatric, Peking University First Hospital, No.1 Xi An Men Da Jie, Beijing, China
| | - Xinmiao Shi
- Department of Pediatric, Peking University First Hospital, No.1 Xi An Men Da Jie, Beijing, China
| | - Lu Xu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Haidian District, No.38, Xueyuan Rd, Beijing, China
| | - Lili Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Haidian District, No.38, Xueyuan Rd, Beijing, China
| | - Fang Wang
- Department of Pediatric, Peking University First Hospital, No.1 Xi An Men Da Jie, Beijing, China
| | - Xuhui Zhong
- Department of Pediatric, Peking University First Hospital, No.1 Xi An Men Da Jie, Beijing, China
| | - Guozhen Liu
- Peking University Health Information Technology Co. Ltd, Beijing, China
| | - Jinxi Wang
- Shanghai Songsheng Business Consulting Co. LTD, Beijing, China
| | - Pei Gao
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Haidian District, No.38, Xueyuan Rd, Beijing, China
| | - Jie Ding
- Department of Pediatric, Peking University First Hospital, No.1 Xi An Men Da Jie, Beijing, China.
| | - Shengfeng Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Haidian District, No.38, Xueyuan Rd, Beijing, China.
| | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Haidian District, No.38, Xueyuan Rd, Beijing, China. .,Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China.
| |
Collapse
|
26
|
Bandaru SS. Atypical Hemolytic Uremic Syndrome Caused by a Rare Complement Factor B Mutation. Cureus 2022; 14:e23207. [PMID: 35317246 PMCID: PMC8934198 DOI: 10.7759/cureus.23207] [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] [Accepted: 03/15/2022] [Indexed: 12/04/2022] Open
Abstract
Thrombotic microangiopathy (TMA), a rare and diagnostically challenging condition, commonly presents with a triad of thrombocytopenia, hemolytic anemia, and end-organ damage, such as renal failure. Most cases of the hemolytic uremic syndrome (HUS) are mediated by Shiga toxin-producing Escherichia coli, but some cases present as an atypical HUS, which includes thrombotic thrombocytopenic purpura and complement-mediated thrombotic microangiopathy (C-TMA). Although C-TMA occurs because of genetic and acquired mutations in the complement regulatory factors, it is usually hereditary. The currently available treatment options include therapeutic plasma exchange and administration of eculizumab, which is a monoclonal antibody against C5. Here, we report a diagnostically challenging and extremely rare case of a middle-aged Caucasian man who was diagnosed with atypical HUS that was caused by a mutation in complement factor B. This case highlights the importance of not overlooking rare causes of TMAs because the diagnostic evaluation is important for guiding appropriate management and obtaining a favorable prognosis.
Collapse
|
27
|
OZTURK İ, GÖK S, SAYLAK HK, ERKEN E, ALTUNÖREN O, GÜNGÖR Ö. NADİR BİR HEMOLİTİK ÜREMİK SENDROM NEDENİ: SALMONELLA TYPHİİ. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2022. [DOI: 10.17517/ksutfd.1026255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Hemolitik üremik sendrom (HÜS), mikroanjiyopatik hemolitik anemi, trombositopeni ve akut böbrek yetmezliği ile karakterize olan ciddi bir hastalıktır. Hızlı tanı konulup uygun tedavi başlanmadığı takdirde ölümcül seyredebilir. Etyolojide enfeksiyöz ajanlar sıklıkla suçlanmaktadır. Genellikle verositotoksin (Shiga benzeri toksin) üreten mikroorganizmalara bağlı enfeksiyonlar etyolojide önemli yer almaktadır. Bu enfeksiyonlardan sorumlu patojenler çoğunlukla Enterohemorajik Escherichia coli (EHEC), Shigella dysanteria tip 1, daha nadir olarak da Citrobacter freundi olarak bildirilmiştir. Daha nadir olarak Streptococcus pneumoniae, HIV, Clostiridium difficile’ye bağlı HÜS vakaları literatürde bildirilmiştir. Bu olgu, 28 yaşındaki erkek hastada gelişen HÜS tablosunun etyolojisinde çok nadir görülen bir etken olan Salmonella Typhii’nin tesbit edilmesi nedeniyle sunulmuştur.
Collapse
Affiliation(s)
- İlyas OZTURK
- KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNİ NEFROLOJİ BİLİM DALI
| | - Serdal GÖK
- KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNİVERSİTESİ, TIP FAKÜLTESİ, TIP PR
| | | | | | | | - Özkan GÜNGÖR
- KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNİVERSİTESİ, TIP FAKÜLTESİ
| |
Collapse
|
28
|
Hamza SB. Severe SARS-COV-2 infection in pediatric patient with atypical Hemolytic Uremic Syndrome: A case report. Ann Med Surg (Lond) 2022; 75:103400. [PMID: 35228868 PMCID: PMC8867980 DOI: 10.1016/j.amsu.2022.103400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/10/2022] [Accepted: 02/21/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction and important There is a high incidence of acute kidney injury with COVID-19 infections. We report a child with atypical Hemolytic Uremic Syndrome (aHUS) admitted to Intensive care Unit (ICU) due to severe SARS-COV-2 infection. Children are recognised as at lower risk of severe COVID-19 compared with adults, but the impact of atypical Hemolytic Uremic Syndrome is yet to be determined. Case presentation An eleven years old male presented to Mohammed Alamin Hamid Pediatric Hospital with generalize body swelling, skin rash and red urine. Examination reveal hepatomegaly and hemic murmur. Investigations reveal anemia, normal platelets, and impaired renal function. Peripheral blood picture shows shistocytes, crenated RBCs, occasional poikilocytes and mild neutrophilia.During hospital stay the patient developed severe shortness of breath and fever, diagnosed as COVID-19 and required ICU admission 2 days later due to severe respiratory compromised. Clinical discussion An atypical Hemolytic Uremic Syndrome with normal platelets is extremely rare condition. SARS-COV-2 infection in patients atypical Hemolytic Uremic Syndrome has not been reported in literature. Conclusion Our study shown that severe SARS-COV-2 infection can be developed in pediatric patients patients with co-existing atypical Hemolytic Uremic Syndrome. We present a rare case of SARS-COV-2 infection in pediatric patient with aHUS. A typical HUS with normal platelets is extremely rare. No apparent diarrheal prodrome in this case.
Collapse
Affiliation(s)
- Salih Boushra Hamza
- Internal Medicine Department, Faculty of Medicine and Health Sciences, Omdurman Islamic University, Khartoum, Sudan.,PSO_Research Unit, Sudan
| |
Collapse
|
29
|
Daily ZH, Rizvi SS, Baez-Bonilla R. Atypical Hemolytic Uremic Syndrome in a Patient With Metastatic Peritoneal Serous Carcinoma: A Case Report. Cureus 2022; 14:e22624. [PMID: 35371768 PMCID: PMC8958130 DOI: 10.7759/cureus.22624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2022] [Indexed: 11/15/2022] Open
Abstract
Atypical hemolytic uremic syndrome (HUS) is a part of a large category of diseases known as thrombotic microangiopathies that present with hemolytic anemia, thrombocytopenia, and target organ damage mostly characterized by acute kidney injury. It is a rare and challenging diagnosis due to the complex pathophysiology underlying the disease and its overlap with other conditions. We report the case of atypical hemolytic uremic syndrome in a 61-year-old female with a history of metastatic peritoneal serous carcinoma of the ovary presenting with anemia and acute renal failure.
Collapse
|
30
|
Severe Thrombotic Thrombocytopenic Purpura (TTP) with Organ Failure in Critically Ill Patients. J Clin Med 2022; 11:jcm11041103. [PMID: 35207375 PMCID: PMC8874413 DOI: 10.3390/jcm11041103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/07/2022] [Accepted: 02/17/2022] [Indexed: 01/27/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a multiorgan disorder. Organ dysfunction occurs as a consequence of widespread microvascular thrombosis, especially in the heart, brain and kidney, causing transient or partial occlusion of vessels, resulting in organ ischemia. Intensive care unit (ICU) admission varies between 40% and 100% of patients with TTP, either because of severe organ failure or in order to initiate emergency plasma exchange (PEx). Severe neurologic manifestations and cardiac involvement have been associated with higher mortality. Acute kidney injury, although usually less severe than that in hemolytic and uremic syndrome, is common during TTP. Initial management in the ICU should always be considered in TTP patients. The current treatment of TTP in the acute phase is based on urgent PEx, combined with corticosteroid therapy, B-cell-targeted immunotherapy, rituximab and inhibition of the interaction between ultra-large Von Willebrand factor multimers and platelets, using caplacizumab, a monoclonal antibody. ICU management permits close monitoring and the rapid introduction of life-sustaining therapies. This review details the epidemiology of TTP in the ICU, organ failures of critically ill patients with TTP, and the initial management of TTP patients in the ICU.
Collapse
|
31
|
Leatherdale A, Stukas S, Lei V, West HE, Campbell CJ, Hoiland RL, Cooper J, Wellington CL, Sekhon MS, Pryzdial ELG, Conway EM. Persistently elevated complement alternative pathway biomarkers in COVID-19 correlate with hypoxemia and predict in-hospital mortality. Med Microbiol Immunol 2022; 211:37-48. [PMID: 35034207 PMCID: PMC8761108 DOI: 10.1007/s00430-021-00725-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 11/29/2021] [Indexed: 01/05/2023]
Abstract
Mechanisms underlying the SARS-CoV-2-triggered hyperacute thrombo-inflammatory response that causes multi-organ damage in coronavirus disease 2019 (COVID-19) are poorly understood. Several lines of evidence implicate overactivation of complement. To delineate the involvement of complement in COVID-19, we prospectively studied 25 ICU-hospitalized patients for up to 21 days. Complement biomarkers in patient sera and healthy controls were quantified by enzyme-linked immunosorbent assays. Correlations with respiratory function and mortality were analyzed. Activation of complement via the classical/lectin pathways was variably increased. Strikingly, all patients had increased activation of the alternative pathway (AP) with elevated levels of activation fragments, Ba and Bb. This was associated with a reduction of the AP negative regulator, factor (F) H. Correspondingly, terminal pathway biomarkers of complement activation, C5a and sC5b-9, were significantly elevated in all COVID-19 patient sera. C5a and AP constituents Ba and Bb, were significantly associated with hypoxemia. Ba and FD at the time of ICU admission were strong independent predictors of mortality in the following 30 days. Levels of all complement activation markers were sustained throughout the patients’ ICU stays, contrasting with the varying serum levels of IL-6, C-reactive protein, and ferritin. Severely ill COVID-19 patients have increased and persistent activation of complement, mediated strongly via the AP. Complement activation biomarkers may be valuable measures of severity of lung disease and the risk of mortality. Large-scale studies will reveal the relevance of these findings to thrombo-inflammation in acute and post-acute COVID-19.
Collapse
Affiliation(s)
- Alexander Leatherdale
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sophie Stukas
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Victor Lei
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Henry E West
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Vancouver, BC, Canada
| | - Jennifer Cooper
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Cheryl L Wellington
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Edward L G Pryzdial
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Canadian Blood Services, Centre for Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Edward M Conway
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada.
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.
| |
Collapse
|
32
|
Shiga Toxin-Associated Hemolytic Uremic Syndrome. Am J Med Sci 2022; 364:e6-e7. [DOI: 10.1016/j.amjms.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/09/2021] [Accepted: 01/19/2022] [Indexed: 11/21/2022]
|
33
|
Stone JR. Diseases of small and medium-sized blood vessels. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
|
34
|
Osugi Y, Ishiguro K, Kobayashi D. Association Between Antidiarrheal Drug Prescription and Return Visits Among Adult Patients With Acute Diarrhea. Cureus 2021; 13:e18807. [PMID: 34796079 PMCID: PMC8590859 DOI: 10.7759/cureus.18807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2021] [Indexed: 11/20/2022] Open
Abstract
Whether antidiarrheal medications have benefits or demerits when administered to adult patients with diarrhea remains controversial. We aimed to evaluate the association between antidiarrheal drug prescription and clinical outcomes in adult patients with acute diarrhea. This retrospective cohort study was conducted by collecting secondary data of patients' health records at St. Luke’s International Hospital from April 1, 2004, to March 31, 2016. We included all participants aged 20-59 years who visited the division of general internal medicine or the emergency room in the hospital due to acute diarrheal symptoms. We excluded those who had chronic diarrhea or were immunocompromised (e.g., those with cancer or immunosuppressant usage). Our primary outcome was return visits within two weeks; the secondary outcome was admission to the hospital due to acute diarrhea within two weeks from the first visit. We compared the outcomes between patients with and without antidiarrheal drug prescriptions. During the study period, a total of 10,246 patients were included, of which 204 (2.0%) were prescribed antidiarrheal drugs. The mean age of the patients was 35.0 (standard deviation: 10.7) years, and 4,130 (40.3%) were men. Patients who were prescribed antidiarrheal drugs were more likely to be prescribed antibiotics (p<0.01). The adjusted odds ratios for return visits among patients with and without antidiarrheal drug prescription were 1.24-1.59, which were not significant. We demonstrated that antidiarrheal drug prescription was not associated with return visits or hospital admission among adult patients with acute diarrhea. This finding suggests that antidiarrheal medications have more benefits than risks in adult patients with acute diarrhea.
Collapse
Affiliation(s)
- Yasuhiro Osugi
- General Medicine, Toyota Regional Medical Center, Toyota, JPN
| | | | | |
Collapse
|
35
|
Cañas CA, Vecino MJ, Posso-Osorio I. Atypical Hemolytic Uremic Syndrome in a Patient With Bothrops asper Envenomation. Wilderness Environ Med 2021; 33:109-115. [PMID: 34740531 DOI: 10.1016/j.wem.2021.08.010] [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: 04/30/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/29/2022]
Abstract
Bothrops asper envenomation is common in Colombia and is characterized by local tissue injury and venom-induced consumption coagulopathy (VICC). Rarely, thrombotic microangiopathy is associated with envenomation by this species. The case of a 57-y-old man with B asper bite and envenomation on the left foot is presented. The patient was admitted 8 h after the event and progressively developed edema, hemorrhage at the site of the bite, and hemorrhagic blisters. His coagulation test results (prothrombin and partial thromboplastin times) were prolonged, and his fibrinogen levels were severely reduced. The diagnosis of VICC was made. Administration of Colombian polyvalent viper antivenom controlled the VICC within a few hours. Subsequently, the patient developed severe microangiopathic anemia, thrombocytopenia, and acute kidney injury. A diagnosis of thrombotic microangiopathy was made, and the patient met the criteria for hemolytic uremic syndrome. Management with hemodialysis in addition to therapeutic plasma exchange and replacement with fresh frozen plasma was indicated. The patient's condition resolved 14 d later. To the best of our knowledge, this is the first case of B asper envenomation in which the patient presented with hemolytic uremic syndrome after VICC. A proposal is made regarding the pathogenesis of this chain of events.
Collapse
Affiliation(s)
- Carlos A Cañas
- Department of Internal Medicine, Unit of Rheumatology, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia.
| | - Milly J Vecino
- Department of Internal Medicine, Unit of Rheumatology, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Iván Posso-Osorio
- Department of Internal Medicine, Unit of Rheumatology, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| |
Collapse
|
36
|
Long B, Bridwell RE, Manchanda S, Gottlieb M. Evaluation and Management of Thrombotic Thrombocytopenic Purpura in the Emergency Department. J Emerg Med 2021; 61:674-682. [PMID: 34518045 DOI: 10.1016/j.jemermed.2021.07.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/15/2021] [Accepted: 07/25/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a dangerous condition that can be misdiagnosed in the emergency department. OBJECTIVE The purpose of this narrative review article is to provide a summary of the background, pathophysiology, diagnosis, and management of TTP, with a focus on emergency clinicians. DISCUSSION TTP is a disorder with microangiopathic hemolytic anemia, severe thrombocytopenia, and multiorgan ischemic injury. It may be acquired or hereditary, and is caused by a reduced amount or function of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), which is an enzyme involved in cleaving von Willebrand factor. The classic presentation of TTP includes fever, neurologic abnormalities, thrombocytopenia with purpura, microangiopathic hemolytic anemia, and acute renal injury. However, < 7% of cases have all of these findings present. Testing should include a complete blood count, complete metabolic panel, blood smear, coagulation panel, fibrinogen, D-dimer, lactate dehydrogenase, ADAMTS13 level, troponin, human immunodeficiency virus assessment, urinalysis, pregnancy test as appropriate, and electrocardiogram. Management includes hematology consultation if available, plasma exchange and corticosteroids, and treatment of end-organ complications. All patients require admission for treatment and close monitoring. CONCLUSION TTP is a potentially dangerous medical condition requiring rapid diagnosis and management. It is essential for emergency clinicians to know how to diagnose and treat this disorder.
Collapse
Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Rachel E Bridwell
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Shivon Manchanda
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
37
|
Hemoglobinuria for the early identification of STEC-HUS in high-risk children: data from the ItalKid-HUS Network. Eur J Pediatr 2021; 180:2791-2795. [PMID: 33759020 DOI: 10.1007/s00431-021-04016-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/01/2021] [Accepted: 03/04/2021] [Indexed: 10/21/2022]
Abstract
Hemolytic uremic syndrome (HUS) represents one of the main causes of severe acute kidney injury in children. The most frequent form of HUS is caused by Shiga toxin-2 (Stx2)-producing Escherichia coli. Hemoglobinuria and hematuria are markers of glomerular damage, but their use has never been validated in HUS. We retrospectively analyzed the presence of hemoglobinuria/urinary red blood cells (RBCs) in children with Stx2-positive bloody diarrhea (BD) or with already ongoing STEC-HUS with the aim of validating its role in early identifying HUS. We reviewed all the pediatric patients with Stx2+ BD (group 1) and with ongoing HUS (group 2) referred to our center from 2010 to 2019. A total of 100 children were eligible for the study. In group 1, 22 patients showed hemoglobinuria/hematuria, while 41 remained negative. In 15/22 positive patients (68.2%), blood tests ruled in HUS, while in 7 (31.8%), HUS was excluded. Among the 41 patients persistently negative for hemoglobinuria/hematuria, no one developed HUS. The 37 STEC-HUS children (group 2) all had hemoglobinuria/RBCs at admission.Conclusion: Hemoglobinuria/hematuria for the diagnosis of HUS in children with Stx2+ BD showed a sensitivity of 100% and a specificity of 85%. We strongly recommend patients with BD carrying Stx2 in stools to be closely monitored with urine dipstick/urinalysis to early identify HUS. What is Known • Children with bloody diarrhea secondary to Shiga toxin 2 are at high risk of hemolytic uremic syndrome, thus have to be carefully monitored for the development of the disease, in order to early be hospitalized and treated. What is New • Urine dipstick for hemoglobinuria can be used as an easy, inexpensive, and repeatable tool to early diagnose children with bloody diarrhea secondary to Shiga toxin 2 to have developed hemolytic uremic syndrome, with no risk of false-negative results.
Collapse
|
38
|
Htet Z, Karim M. Thrombotic microangiopathy with renal injury: an approach for the general physician. J R Coll Physicians Edinb 2021; 50:25-31. [PMID: 32539032 DOI: 10.4997/jrcpe.2020.107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Thrombotic microangiopathy with renal dysfunction is a haematological and renal emergency warranting urgent diagnosis and intervention. As the potential underlying causes may be complex, assessment and management can be challenging for treating clinicians, and a timely and collaborative approach between general physicians, haematologists and nephrologists may be extremely helpful in order to optimise clinical outcomes. This paper will aim to build an understanding of different potential presentations of thrombotic microangiopathies and provide a practical framework for diagnosis and management, using a case-based discussion format, for acute and general physicians. Some aspects of subsequent specialist management are also discussed.
Collapse
Affiliation(s)
- Zay Htet
- Department of Renal Medicine, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK,
| | - Mahzuz Karim
- Department of Renal Medicine, Norfolk and Norwich University Hospital, Norwich, UK
| |
Collapse
|
39
|
Patient-specific iPSC-derived endothelial cells reveal aberrant p38 MAPK signaling in atypical hemolytic uremic syndrome. Stem Cell Reports 2021; 16:2305-2319. [PMID: 34388364 PMCID: PMC8452517 DOI: 10.1016/j.stemcr.2021.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 07/13/2021] [Accepted: 07/15/2021] [Indexed: 11/24/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease associated with high morbidity and mortality. Existing evidence suggests that the central pathogenesis to aHUS might be endothelial cell damage. Nevertheless, the role of endothelial cell alterations in aHUS has not been well characterized and the underlying mechanisms remain unclear. Utilizing an induced pluripotent stem cell-derived endothelial cell (iPSC-EC) model, we showed that anti-complement factor H autoantibody-associated aHUS patient-specific iPSC-ECs exhibited an intrinsic defect in endothelial functions. Stimulation using aHUS serums exacerbated endothelial dysfunctions, leading to cell apoptosis in iPSC-ECs. Importantly, we identified p38 as a novel signaling pathway contributing to endothelial dysfunctions in aHUS. These results illustrate that iPSC-ECs can be a reliable model to recapitulate EC pathological features, thus providing a unique platform for gaining mechanistic insights into EC injury in aHUS. Our findings highlight that the p38 MAPK signaling pathway can be a therapeutic target for treatment of aHUS. aHUS patient-specific iPSC-ECs exhibit intrinsic defect in endothelial functions Stimulation using aHUS serums exacerbates EC dysfunctions and causes EC apoptosis p38 signaling contributes to EC dysfunctions in anti-CFH Ab-associated aHUS
Collapse
|
40
|
Simpson HD, Johnson E, Britton J, Braksick S. Alternating hemiparesis in the context of hemolytic uremic syndrome and COVID-19 positivity. Epilepsy Behav Rep 2021; 16:100468. [PMID: 34250459 PMCID: PMC8256673 DOI: 10.1016/j.ebr.2021.100468] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 11/24/2022] Open
Abstract
Hemiparesis has been reported in hemolytic uremic syndrome (HUS), however electrophysiological findings associated with this syndrome have not been well-characterized, and alternating hemiparesis presentations have not been reported. We present detailed electrophysiological and clinical findings in a case of alternating hemiparesis corresponding to alternating focal contralateral delta slowing on prolonged EEG monitoring in a case of HUS with COVID-19 positivity. A 24-year-old woman was admitted with bloody diarrhea, acute kidney injury, and focal seizures initially presumed due to Escherichia coli 0157:H7 Shiga-like toxin-related hemolytic uremic syndrome (ST-HUS). After admission, the patient tested positive for COVID-19. Continuous EEG monitoring revealed diffuse polymorphic delta slowing. Around 24 hours into the admission, the delta slowing became focal in the right hemisphere and was associated with a left hemiparesis. Around three days later, the clinical and EEG pattern reversed, showing left hemisphere slowing and an associated right hemiparesis. Additionally, 14 Hz positive spikes were observed throughout the recording period. Neuroimaging, including CT and MRI, was negative for acute ischemia throughout. The patient subsequently recovered over several days with no residual neurologic abnormalities.
Collapse
Affiliation(s)
| | - Erica Johnson
- Division of Critical Care and Hospital Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Sherri Braksick
- Division of Critical Care and Hospital Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
41
|
Rossi M, Pessolano G, Caletti C, De Biase V, Gambaro G. Mixed typical and atypical hemolytic uremic syndrome in a kidney transplant patient. J Nephrol 2021; 35:343-346. [PMID: 34224089 DOI: 10.1007/s40620-021-01112-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 06/21/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Mattia Rossi
- Division of Nephrology, Department of Medicine, University of Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy.
| | - Giuseppina Pessolano
- Division of Nephrology, Department of Medicine, University of Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy
| | - Chiara Caletti
- Division of Nephrology, Department of Medicine, University of Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy
| | - Vincenzo De Biase
- Division of Nephrology, Department of Medicine, University of Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy
| | - Giovanni Gambaro
- Division of Nephrology, Department of Medicine, University of Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy
| |
Collapse
|
42
|
Mounier S, Gavotto A, Tenenbaum J, Meyer P, Fila M, Baleine J. Hemolytic uremic syndrome related to Shiga-like toxin-producing Escherichia coli with encephalitis hiding a human herpesvirus-6 infection: a case report. J Med Case Rep 2021; 15:300. [PMID: 34034812 PMCID: PMC8152054 DOI: 10.1186/s13256-021-02873-8] [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] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 04/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac and neurological involvement in hemolytic uremic syndrome are life-threatening complications. The most frequent complications of cardiac involvement in hemolytic uremic syndrome are myocarditis and cardiac dysfunction due to fluid overload. Pericarditis remains very rare in hemolytic uremic syndrome. To our knowledge, only five cases of cardiac tamponade associated with hemolytic uremic syndrome have been described in literature. A 27-month-old Caucasian girl presented with symptoms of nonbloody diarrhea and tonic-clonic seizures. The diagnosis of Shiga-like toxin-producing Escherichia coli hemolytic uremic syndrome with central nervous system involvement was made, and stool examination revealed infection with a Shiga-like toxin-producing Escherichia coli. She did not need renal replacement therapy but had severe neurological impairment. The patient's course was complicated by pericardial effusion. A pericardiocentesis was performed via an apical approach because the pericardial effusion was predominantly surrounding the left ventricle. Effusion analysis showed an exudate and positivity for human herpesvirus-6B on polymerase chain reaction with viremia. This finding was consistent with primary human herpesvirus-6 infection with encephalitis. CONCLUSION We report this uncommon case of Shiga-like toxin-producing Escherichia coli hemolytic uremic syndrome associated with a severe human herpesvirus-6 infection. Secondary isolated pericardial effusion and atypical neurological involvement are uncommon in Shiga-like toxin-producing Escherichia coli hemolytic uremic syndrome and should lead the physician to perform additional investigations.
Collapse
Affiliation(s)
- Sophie Mounier
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France.
| | - Arthur Gavotto
- Department of Pediatric Cardiology, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
- CNRS, INSERM, University of Montpellier, PhyMedExpMontpellier, France
| | - Julie Tenenbaum
- Department of Pediatric Nephrology, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Pierre Meyer
- CNRS, INSERM, University of Montpellier, PhyMedExpMontpellier, France
- Department of Pediatric Neurology, Gui de Chauliac Hospital, Montpellier University Hospital Center, 80 Avenue Augustin Fliche, 34090, Montpellier, France
| | - Marc Fila
- Department of Pediatric Nephrology, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Julien Baleine
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| |
Collapse
|
43
|
Hua Y, Chromek M, Frykman A, Jernberg C, Georgieva V, Hansson S, Zhang J, Marits AK, Wan C, Matussek A, Bai X. Whole-genome characterization of hemolytic uremic syndrome-causing Shiga toxin-producing Escherichia coli in Sweden. Virulence 2021; 12:1296-1305. [PMID: 33939581 PMCID: PMC8096335 DOI: 10.1080/21505594.2021.1922010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Shiga toxin-producing Escherichia coli, a foodborne bacterial pathogen, has been linked to a broad spectrum of clinical outcomes ranging from asymptomatic carriage to fatal hemolytic uremic syndrome (HUS). Here, we collected clinical data and STEC strains from HUS patients from 1994 through 2018, whole-genome sequencing was performed to molecularly characterize HUS-associated STEC strains, statistical analysis was conducted to identify bacterial genetic factors associated with severe outcomes in HUS patients. O157:H7 was the most predominant serotype (57%) among 54 HUS-associated STEC strains, followed by O121:H19 (19%) and O26:H11 (7%). Notably, some non-predominant serotypes such as O59:H17 (2%) and O109:H21 (2%) also caused HUS. All O157:H7 strains with one exception belonged to clade 8. During follow-up at a median of 4 years, 41% of the patients had renal sequelae. Fifty-nine virulence genes were found to be statistically associated with severe renal sequelae, these genes encoded type II and type III secretion system effectors, chaperones, and other factors. Notably, virulence genes associated with severe clinical outcomes were significantly more prevalent in O157:H7 strains. In contrast, genes related to mild symptoms were evenly distributed across all serotypes. The whole-genome phylogeny indicated high genomic diversity among HUS-STEC strains. No distinct cluster was found between HUS and non-HUS STEC strains. The current study showed that O157:H7 remains the main cause of STEC-associated HUS, despite the rising importance of other non-O157 serotypes. Besides, O157:H7 is associated with severe renal sequelae in the follow-up, which could be a risk factor for long-term prognosis in HUS patients.
Collapse
Affiliation(s)
- Ying Hua
- Department of Microbiology, School of Public Health, Southern Medical University, Guangzhou, China.,Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Sweden
| | - Milan Chromek
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Anne Frykman
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Valya Georgieva
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Sverker Hansson
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ji Zhang
- Molecular Epidemiology and Public Health Laboratory, School of Veterinary Sciences, Massey University, Palmerston North, New Zealand
| | - Ann Katrine Marits
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Chengsong Wan
- Department of Microbiology, School of Public Health, Southern Medical University, Guangzhou, China
| | - Andreas Matussek
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Sweden.,Laboratory Medicine, Jönköping Region County, Department of Clinical and Experimental Medicine, Linköping University, Jönköping, Sweden.,Oslo University Hospital, Oslo, Norway.,Division of Laboratory Medicine, Institute of Clinical Medicine, University of Oslo, Norway
| | - Xiangning Bai
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Sweden.,Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Huddinge, Sweden.,State Key Laboratory of Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| |
Collapse
|
44
|
Lin CY, Xie J, Freedman SB, McKee R, Schnadower D, Tarr PI, Finkelstein Y, Desai NM, Lane RD, Bergmann KR, Kaplan RL, Hariharan S, Cruz AT, Cohen DM, Dixon A, Ramgopal S, Powell EC, Kilgar J, Michelson KA, Bitzan M, Yen K, Meckler GD, Plint AC, Balamuth F, Bradin S, Gouin S, Kam AJ, Meltzer J, Hunley TE, Avva U, Porter R, Fein DM, Louie JP, Tarr GA. Predicting Adverse Outcomes for Shiga Toxin-Producing Escherichia coli Infections in Emergency Departments. J Pediatr 2021; 232:200-206.e4. [PMID: 33417918 PMCID: PMC8084908 DOI: 10.1016/j.jpeds.2020.12.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the performance of a hemolytic uremic syndrome (HUS) severity score among children with Shiga toxin-producing Escherichia coli (STEC) infections and HUS by stratifying them according to their risk of adverse events. The score has not been previously evaluated in a North American acute care setting. STUDY DESIGN We reviewed medical records of children <18 years old infected with STEC and treated in 1 of 38 participating emergency departments in North America between 2011 and 2015. The HUS severity score (hemoglobin [g/dL] plus 2-times serum creatinine [mg/dL]) was calculated using first available laboratory results. Children with scores >13 were designated as high-risk. We assessed score performance to predict severe adverse events (ie, dialysis, neurologic complication, respiratory failure, and death) using discrimination and net benefit (ie, threshold probability), with subgroup analyses by age and day-of-illness. RESULTS A total of 167 children had HUS, of whom 92.8% (155/167) had relevant data to calculate the score; 60.6% (94/155) experienced a severe adverse event. Discrimination was acceptable overall (area under the curve 0.71, 95% CI 0.63-0.79) and better among children <5 years old (area under the curve 0.77, 95% CI 0.68-0.87). For children <5 years, greatest net benefit was achieved for a threshold probability >26%. CONCLUSIONS The HUS severity score was able to discriminate between high- and low-risk children <5 years old with STEC-associated HUS at a statistically acceptable level; however, it did not appear to provide clinical benefit at a meaningful risk threshold.
Collapse
Affiliation(s)
- Chu Yang Lin
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jianling Xie
- Section of Pediatric Emergency Medicine, Department of Pediatric, Alberta Children Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children’s Hospital and Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Ryan McKee
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - David Schnadower
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Phillip I. Tarr
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Yaron Finkelstein
- Divisions of Emergency Medicine and Clinical Pharmacology & Toxicology, Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Neil M. Desai
- British Columbia Children’s Hospital Division of Pediatric Emergency Medicine
| | - Roni D. Lane
- Division of Pediatric Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Ron L. Kaplan
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, WA
| | - Selena Hariharan
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Andrea T. Cruz
- Pediatric Emergency Medicine and Pediatric Infectious Diseases, Baylor College of Medicine
| | - Daniel M. Cohen
- Professor of Clinical Pediatrics, Nationwide Children’s, Professor of Clinical Pediatrics, Nationwide Children’s Hospital & The Ohio State University, Columbus, OH
| | - Andrew Dixon
- University of Alberta, Stollery Children’s Hospital, Women’s and Children’s Health Research Institute
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Elizabeth C. Powell
- Professor of Pediatrics, Northwestern University Feinberg School of Medicine; Ann & Robert H. Lurie Children’s Hospital of Chicago; Division of Emergency Medicine
| | - Jennifer Kilgar
- Department or Pediatrics & Division of Emergency Medicine, Children’s Hospital, Schulich School of Medicine and Dentistry, Western University, London, Ontario
| | | | - Martin Bitzan
- Division of Nephrology, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Canada; A1 Jalila Children’s Hospital, Kidney Centre of Excellence, Dubai, UAE
| | - Kenneth Yen
- Pediatric Emergency Medicine, Children’s Medical Center, UT Southwestern
| | - Garth D. Meckler
- Pediatrics and Emergency Medicine; University of British Columbia, Vancouver, BC
| | - Amy C. Plint
- Departments of Pediatrics and Emergency Medicine, University of Ottawa and the Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Fran Balamuth
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine; Division of Emergency Medicine, Children’s Hospital of Philadelphia
| | - Stuart Bradin
- Children’s Emergency Services, Department of Emergency Medicine, University of Michigan Medical School
| | - Serge Gouin
- Professor, Departments of Pediatric Emergency Medicine & Pediatrics, CHU Sainte-Justine, Universite de Montreal, QC, Canada
| | - April J. Kam
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University
| | - James Meltzer
- Division of Emergency Medicine; Department of Pediatrics; Jacobi Medical Center
| | - Tracy E. Hunley
- Division of Pediatric Nephrology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Usha Avva
- Department of Pediatrics, Joseph M Sanzari Women and Children’s Hospital, Hackensack University Medical Center
| | - Robert Porter
- Discipline of Pediatrics, Memorial University of Newfoundland
| | - Daniel M. Fein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | - Jeffrey P. Louie
- Division of Emergency Medicine, University of Minnesota, Masonic Children’s Hospital
| | - Gillian A.M. Tarr
- Division of Environmental Health Sciences, University of Minnesota, Minneapolis, MN
| | | |
Collapse
|
45
|
Influenza-associated hemolytic uremic syndrome: The pathogenic role of the virus. Clin Nephrol Case Stud 2021; 9:45-48. [PMID: 33884256 PMCID: PMC8056317 DOI: 10.5414/cncs110219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 01/26/2021] [Indexed: 11/18/2022] Open
Abstract
A 3-year-old girl came to our attention for fever and upper respiratory tract infection associated with thrombocytopenia, non-immune hemolytic anemia, and acute kidney injury (AKI). Complete blood count and renal function slowly normalized, with no need for dialysis. She was always normotensive with valid diuresis; her neurological status also rapidly improved. Nasal swab turned out positive for influenza A H1N1; stool test was negative for Shiga toxin-producing Escherichia coli (STEC). The patient was treated with oseltamivir for 5 days with a favorable outcome. Association between hemolytic uremic syndrome (HUS) and H1N1 influenza is poorly reported in literature [1, 2, 3, 4]. The pathogenic role of the virus in causing HUS is still controversial and debated [1, 2, 3, 4]. In our patient, complement activity markers (serum C3 and C5b-9) alteration suggested a transient, virus-mediated complement activation.
Collapse
|
46
|
Furmańczyk-Zawiska A, Kubiak-Dydo A, Użarowska-Gąska E, Kotlarek-Łysakowska M, Salata K, Kolanowska M, Świerniak M, Gaj P, Leszczyńska B, Daniel M, Jażdżewski K, Durlik M, Wójcicka A. Compound Haplotype Variants in CFH and CD46 Genes Determine Clinical Outcome of Atypical Hemolytic Uremic Syndrome (aHUS)-A Series of Cases from a Single Family. J Pers Med 2021; 11:jpm11040304. [PMID: 33920896 PMCID: PMC8071215 DOI: 10.3390/jpm11040304] [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: 03/26/2021] [Revised: 04/11/2021] [Accepted: 04/12/2021] [Indexed: 11/16/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease triggered by dysregulation of the alternative complement pathway, consisting of a characteristic triad of nonimmune hemolytic anemia, thrombocytopenia, and renal failure. The risk of aHUS onset, recurrence, and allograft loss depends on the genetic background of a patient. We show a series of cases from a single family whose five members were affected by aHUS and presented distinct clinical outcomes. Next-generation sequencing revealed combined mutations in both complement factor H and membrane cofactor protein CD46. Out of eight siblings, aHUS affected three adult brothers, and, subsequently, affected two children of an unaffected sister. The first patient died due to aHUS, and two other brothers underwent successful kidney transplantation with no aHUS recurrence. The younger, 10-month-old child presented with a severe course of the disease with cardiac involvement and persistent hemolytic anemia limited by eculizumab, while the 2-year-old recovered completely on eculizumab. The study shows a highly variable disease penetrance.
Collapse
Affiliation(s)
- Agnieszka Furmańczyk-Zawiska
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, 02-006 Warsaw, Poland; (A.F.-Z.); (M.D.)
| | - Anna Kubiak-Dydo
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
| | - Ewelina Użarowska-Gąska
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
- Postgraduate School of Molecular Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Marta Kotlarek-Łysakowska
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
| | - Katarzyna Salata
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
| | - Monika Kolanowska
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
| | - Michał Świerniak
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
| | - Paweł Gaj
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
| | - Beata Leszczyńska
- Department of Pediatrics Nephrology, Medical University of Warsaw, 02-091 Warsaw, Poland; (B.L.); (M.D.)
| | - Maria Daniel
- Department of Pediatrics Nephrology, Medical University of Warsaw, 02-091 Warsaw, Poland; (B.L.); (M.D.)
| | - Krystian Jażdżewski
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
- Laboratory of Human Cancer Genetics, University of Warsaw, 02-089 Warsaw, Poland
| | - Magdalena Durlik
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, 02-006 Warsaw, Poland; (A.F.-Z.); (M.D.)
| | - Anna Wójcicka
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
- Correspondence:
| |
Collapse
|
47
|
Pugh D, O'Sullivan ED, Duthie FA, Masson P, Kavanagh D. Interventions for atypical haemolytic uraemic syndrome. Cochrane Database Syst Rev 2021; 3:CD012862. [PMID: 33783815 PMCID: PMC8078160 DOI: 10.1002/14651858.cd012862.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Atypical haemolytic uraemic syndrome (aHUS) is a rare disorder characterised by thrombocytopenia, microangiopathic haemolytic anaemia, and acute kidney injury. The condition is primarily caused by inherited or acquired dysregulation of complement regulatory proteins with ~40% of those affected aged < 18 years. Historically, kidney failure and death were common outcomes, however, improved understanding of the condition has led to discovery of novel therapies. OBJECTIVES To evaluate the benefits and harms of interventions for aHUS. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies for randomised controlled studies (RCTs) up to 3 September 2020 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. MEDLINE(OVID) 1946 to 27 July 2020 and EMBASE (OVID) 1974 to 27 July 2020 were searched for non-RCTs. SELECTION CRITERIA All randomised and non-randomised clinical trials comparing an intervention with placebo, an intervention with supportive therapy, or two or more interventions for aHUS were included. Given the rare nature of the condition in question, prospective single-arm studies of any intervention for aHUS were also included. DATA COLLECTION AND ANALYSIS Two authors independently extracted pre-specified data from eligible studies and evaluated risk of bias using a newly developed tool based on existing Cochrane criteria. As statistical meta-analysis was not appropriate, qualitative analysis of data was then performed. MAIN RESULTS We included five single-arm studies, all of which evaluated terminal complement inhibition for the treatment of aHUS. Four studies evaluated the short-acting C5 inhibitor eculizumab and one study evaluated the longer-acting C5 inhibitor ravulizumab. All included studies within the review were of non-randomised, single-arm design. Thus, risk of bias is high, and it is challenging to draw firm conclusions from this low-quality evidence. One hundred patients were included within three primary studies evaluating eculizumab, with further data reported from 37 patients in a secondary study. Fifty-eight patients were included in the ravulizumab study. After 26 weeks of eculizumab therapy there were no deaths and a 70% reduction in the number of patients requiring dialysis. Complete thrombotic microangiopathic (TMA) response was observed in 60% of patients at 26 weeks and 65% at two years. After 26 weeks of ravulizumab therapy four patients had died (7%) and complete TMA response was observed in 54% of patients. Substantial improvements were seen in estimated glomerular filtration rate and health-related quality of life in both eculizumab and ravulizumab studies. Serious adverse events occurred in 42% of patients, and meningococcal infection occurred in two patients, both treated with eculizumab. AUTHORS' CONCLUSIONS When compared with historical data, terminal complement inhibition appears to offer favourable outcomes in patients with aHUS, based upon very low-quality evidence drawn from five single-arm studies. It is unlikely that an RCT will be conducted in aHUS and therefore careful consideration of future single-arm data as well as longer term follow-up data will be required to better understand treatment duration, adverse outcomes and risk of disease recurrence associated with terminal complement inhibition.
Collapse
Affiliation(s)
- Dan Pugh
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Eoin D O'Sullivan
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Inflammation Research, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Fiona Ai Duthie
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Philip Masson
- Department of Renal Medicine, Royal Free London NHS Foundation Trust, London, UK
| | - David Kavanagh
- Renal Department, Newcastle University/Freeman Hospital, Newcastle Upon Tyne, UK
| |
Collapse
|
48
|
Liu Y, Tian S, Thaker H, Dong M. Shiga Toxins: An Update on Host Factors and Biomedical Applications. Toxins (Basel) 2021; 13:222. [PMID: 33803852 PMCID: PMC8003205 DOI: 10.3390/toxins13030222] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/13/2021] [Accepted: 03/15/2021] [Indexed: 12/18/2022] Open
Abstract
Shiga toxins (Stxs) are classic bacterial toxins and major virulence factors of toxigenic Shigella dysenteriae and enterohemorrhagic Escherichia coli (EHEC). These toxins recognize a glycosphingolipid globotriaosylceramide (Gb3/CD77) as their receptor and inhibit protein synthesis in cells by cleaving 28S ribosomal RNA. They are the major cause of life-threatening complications such as hemolytic uremic syndrome (HUS), associated with severe cases of EHEC infection, which is the leading cause of acute kidney injury in children. The threat of Stxs is exacerbated by the lack of toxin inhibitors and effective treatment for HUS. Here, we briefly summarize the Stx structure, subtypes, in vitro and in vivo models, Gb3 expression and HUS, and then introduce recent studies using CRISPR-Cas9-mediated genome-wide screens to identify the host cell factors required for Stx action. We also summarize the latest progress in utilizing and engineering Stx components for biomedical applications.
Collapse
Affiliation(s)
- Yang Liu
- Department of Nephrology, The First Hospital of Jilin University, Changchun 130021, China
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA; (S.T.); (H.T.)
- Department of Microbiology and Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Songhai Tian
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA; (S.T.); (H.T.)
- Department of Microbiology and Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Hatim Thaker
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA; (S.T.); (H.T.)
- Department of Microbiology and Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Min Dong
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA; (S.T.); (H.T.)
- Department of Microbiology and Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
49
|
Abstract
PURPOSE OF REVIEW To discuss the crosstalk between the complement system and hemostatic factors (coagulation cascade, platelet, endothelium, and Von Willebrand Factor), and the consequences of this interaction under physiologic and pathologic conditions. RECENT FINDINGS The complement and coagulation systems are comprised of serine proteases and are genetically related. In addition to the common ancestral genes, the complement system and hemostasis interact directly, through protein-protein interactions, and indirectly, on the surface of platelets and endothelial cells. The close interaction between the complement system and hemostatic factors is manifested both in physiologic and pathologic conditions, such as in the inflammatory response to thrombosis, thrombosis at the inflamed area, and thrombotic complications of complement disorders. SUMMARY The interaction between the complement system and hemostasis is vital for homeostasis and the protective response of the host to tissue injury, but also results in the pathogenesis of several thrombotic and inflammatory disorders.
Collapse
|
50
|
Wadehra A, Alkassis S. Atypical Hemolytic Uremic Syndrome in the Setting of Acute Clostridium difficile Colitis. Cureus 2021; 13:e13244. [PMID: 33728192 PMCID: PMC7948306 DOI: 10.7759/cureus.13244] [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: 11/24/2022] Open
Abstract
Hemolytic uremic syndrome (HUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. HUS can be secondary to multiple etiologies such as infections, medications, and immune processes. A rare, yet significant, etiology of HUS includes acute Clostridium difficile colitis. Here, we present a case of atypical HUS secondary to acute C. difficile colitis, successfully treated with hemodialysis and systemic corticosteroids. It is imperative that clinicians are cognizant of C. difficile-associated HUS given the overall rising incidence of acute C. difficile infections.
Collapse
Affiliation(s)
- Anshu Wadehra
- Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, USA
| | - Samer Alkassis
- Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, USA
| |
Collapse
|