Adult-onset Still's disease: current challenges and future prospects

Successful Treatment of Recurrent Adult-Onset Still's Disease with Tocilizumab: A Case Report and Literature Review

Adult-onset Still's disease (AOSD) is considered a rare autoimmune inflammatory disorder with an unclear etiology and pathogenesis.The main clinical manifestations of this disease are high fever, joint pain, and transient skin lesions. Physical examination may reveal hepatomegaly, splenomegaly, and lymphadenopathy, while laboratory tests show abnormalities such as elevated white blood cell count (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and serum ferritin (SF). The lack of specific diagnostic markers contributes to a relatively high rate of clinical misdiagnosis and missed diagnoses.In terms of treatment, glucocorticoids have always been the cornerstone medication, but some patients exhibit suboptimal responses to conventional drug therapy, making disease control challenging. However, as our understanding of the pathogenesis continues to grow, novel therapeutic approaches targeting various cytokines have been gradually identified. In this report, we present a case of successful treatment of recurrent AOSD with tocilizumab (TCZ), along with a concise review of innovative treatment strategies for AOSD based on literature retrieval.

Adult-onset Still's disease and fever of unknown origin in India

Despite an essential differential diagnosis for fever of unknown origin (FUO) in young adults, adult-onset Still's disease (AOSD) is infrequently considered and remained underdiagnosed in low-middle-income countries. The present study analyzed the clinical, serological, radiological, and pathological characteristics of AOSD presented as FUO in India. A hospital-based retrospective study of patients aged > 13 years admitted with FUO and later diagnosed with AOSD in Postgraduate Institute of Medical Education and Research, Chandigarh (India), was conducted between January 2014 and December 2020. Petersdorf and Beeson's criteria were used to define FUO. The diagnosis of AOSD was made based on Yamaguchi's criteria. Twenty-seven patients (median age 26 years, 14 females) were enrolled. All presented with intermittent fever with a median duration of 10 weeks. The typical features of AOSD at admission were arthralgia (n = 24), hepatosplenomegaly (n = 21), spiking fever ≥ 39 °C (n = 19), lymphadenopathy (n = 18), typical rash (n = 17), and sore throat (n = 11). Leukocytosis (n = 25) and neutrophilia (n = 19) were frequent. Hyperferritinemia was universal (range, 700-145,003 ng/ml; ≥ 2000, n = 23). At admission, AOSD was suspected in only nine FUO cases, while tuberculosis (n = 16), undifferentiated connective tissue disorder (n = 14), and lymphoproliferative disorder (n = 11) were common diagnostic possibilities. Crispin et al. clinical scale detected AOSD in only 15 (55.5%) FUO patients. Whole-body imaging (n = 27), including fluorodeoxyglucose positron emission tomography (n = 12), demonstrated reticuloendothelial organ-system involvement and serositis. Seventeen (63%) patients had macrophage activation syndrome at the time of AOSD diagnosis. AOSD FUO presents with typical but nonspecific features; thus, early differentiation from common causes (e.g., tuberculosis, lymphoma) is difficult. Macrophage activation syndrome is common in AOSD with FUO presentation.

Bibliometrics analysis on the research status and trends of adult-onset Still’s disease: 1921-2021

Objectives

The aim of this research is to discuss the research status, hotspots, frontiers and development trends in the field of adult-onset Still’s disease (AOSD) based on bibliometrics and visual analysis by CiteSpace software.

Methods

The relevant research articles on AOSD from 1921 to 2021 were retrieved from the Scopus database. CiteSpace software was used to form a visual knowledge map and conduct analysis for the countries/regions, journals, authors, keywords, clusters, research hotspots and frontiers of the included articles.

Results

There were 2,373 articles included, and the number of articles published during 1921-2021 is increasing. The country with the highest number of articles published was Japan (355, 14.96%), followed by the United States (329, 13.86%) and France (215, 9.06%). The author with the highest number of publications is Ansell, Barbara M. (30, 1.26%), and the author with the highest co-citation frequency is Yamaguchi, Masaya (703). Clinical Rheumatology is the journal with the highest publication frequency. The top five cluster groups were “joint”, “differential diagnosis”, “prednisolone”, “methotrexate” and “macrophage activation syndrome”. The diagnosis, treatment and pathogenesis of AOSD form the main research fields, and prognosis and complications are the research hotspots and trends.

Conclusions

The global research field in AOSD has expanded in the past 100 years. The complications and new pathogenesis of AOSD are hotspots in this field and need further study in the future.

Non-Conforming Still's Disease With Low Ferritin and No Skin Rash: A Case Report

Adult Still's disease (ASD) is an inflammatory disorder with an unclear etiology. It is a rare disease that was first described more than a century ago. Its common characteristics are daily fevers, arthritis, and skin rash. ASD is diagnosed after excluding infections, malignancies, and connective tissue diseases. It has a female predominance. Classic skin rash and high serum ferritin levels are commonly associated with this condition and help in the diagnosis. Due to a lack of pathognomic clinical and laboratory features, a valid diagnostic criterion, the Yamaguchi criteria, is generally used for the diagnosis. The disease has a good prognosis with appropriate treatment. We present the case of a young gentleman who presented with fever, anemia, and leucocytosis; however, his serum ferritin levels were normal, and there was no typical salmon-colored skin rash. Hyperferritinemia developed later in the disease course, leading to a diagnosis of ASD.

Macrophage activation syndrome associated with adult-onset Still's disease: a multicenter retrospective analysis

OBJECTIVES

To explore the clinical features, treatments, and prognostic factors of adult-onset Still's disease (AOSD)-associated macrophage activation syndrome (MAS), we conducted a multicenter retrospective clinical study of AOSD-associated MAS patients.

METHODS

AOSD patients were collected from six tertiary hospitals in China. Medical charts were reviewed and clinical information was recorded and analyzed.

RESULTS

There were 447 AOSD patients enrolled into this retrospective clinical study. Among them, 55 were diagnosed with MAS. Liver dysfunction was the most reliable predictive factor for the screening of MAS in AOSD patients (OR = 75.744, 95%CI = 23.015-249.284, p < 0.0001). In multivariate analysis, clinical features including platelets < 100 × 10⁹/L (OR = 9.546, p = 0.005), aspartate transaminase (AST) > 120 U/L (OR = 25.853, p < 0.0001), triglycerides > 3 mmol/L (OR = 12.9833, p = 0.011)), ferritin > 1500 ng/mL (OR = 5.513, p = 0.050), as well as hemophagocytosis in bone puncture (OR = 18.132, p = 0.001) were highly associated with the occurrence of MAS. The mortality rate of total AOSD patients was 4.47%, MAS was the main cause of death in AOSD patients (OR = 11.705, 95%CI = 4.783-28.647, p < 0.0001). PLT ≤ 100 × 10⁹/L (p = 0.0001), fibrinogen < 1.5 g/L (p = 0.0286), splenomegaly (p = 0.0002), and liver dysfunction (p = 0.0008) highly suggested poor prognosis.

CONCLUSION

MAS occurrence is the major cause of death in AOSD patients. Notable liver dysfunction, as well as splenomegaly, low number of platelets or neutrophils, high levels of serum ferritin, and reduced level of fibrinogen are risk factors for poor outcome. Key Points • This is a multicenter retrospective study of AOSD-associated MAS with large number of cases.

Pathogenesis, disease course, and prognosis of adult-onset Still's disease: an update and review

OBJECTIVE

Adult-onset Still's disease (AOSD) is a rare but clinically well-known polygenic systemic autoinflammatory disease. In this review, we aim to present frontiers in the pathogenesis, clinical features, diagnosis, biomarkers, disease course, prognosis, and treatment in AOSD.

DATA SOURCES

We retrieved information from the PubMed database up to July 2019, using various search terms and relevant words, including AOSD and Still's disease.

STUDY SELECTION

We included data from peer-reviewed journals. Both basic and clinical studies were selected.

RESULTS

Pathogenesis of AOSD involves genetic background, infectious triggers, and immunopathogenesis, mainly the activation of macrophages and neutrophils followed by a cytokine storm. Diagnosis and prognosis evaluation of AOSD is still challenging; therefore, there is an urgent need to identify better biomarkers. Biologic agents, including interleukin (IL)-1β, IL-6, and tumor necrosis factor-α antagonists in the treatment of AOSD, have good prospect.

CONCLUSION

This review highlights the advances in pathogenesis, potential biomarkers, disease course, and treatment in AOSD.

Paving a Shorter Path Towards Diagnosis: A Case on Adult Onset Still's Disease from Pakistan

Adult onset Still’s disease (AOSD) is a rare clinical entity with unknown etiology, characterized by arthritis, fever, erythematous rash, and other systemic presentations. We report a case of a 21-year-old male who presented with high spiking fever, dry cough, generalized body ache, arthralgia, and an erythematous rash. He was eventually diagnosed to have AOSD based on the Yamaguchi criteria, after a month of visiting three different healthcare facilities and receiving two misdiagnoses and treatment regimes not specific to his diagnosis. The patient immediately responded to prednisoloneand was healthy upon discharge.

Acute appendicitis complicated with necrotizing fasciitis in a patient with adult-onset Still's disease: A case report

RATIONALE

Adult-onset Still disease (AOSD) is a rare systemic inflammatory disease of unknown etiology characterized by evanescent salmon-pink rash, spiking fever, arthralgia/ arthritis, and lymphadenopathy. AOSD sometimes was fatal when it is complicated by macrophage activation syndrome (MAS) or hemophagocytic lymphohistiocytosis (HLH). Nonetheless, the literature provides no recommendations for treatment of AOSD patients with severe sepsis.

PATIENT CONCERNS

A previously healthy 65-year-old man with history of AOSD was referred to our hospital for persistent right lower quadrant abdominal pain for 2 days. One week later, an abdominal wall abscess and hematoma developed by extravasation from the inferior epigastric vessels, complicated by necrotizing fasciitis of the right thigh and groin region. To our best knowledge, this case was the first reported case of a perforated appendix complicated with necrotizing fasciitis in a patient with AOSD.

DIAGNOSES

The patient was diagnosed as acute appendicitis complicated with necrotizing fasciitis and abdominal wall abscess.

INTERVENTIONS

This case received intravenous tigecycline injection and daily 10 mg prednisolone initially, and shifted to daily intravenous hydrocortisone 200 mg for suspected MAS or HLH. This patient underwent surgical intervention and debridement for necrotizing fasciitis.

OUTCOMES

The patient's symptoms progressed worse rapidly. He died from cytomegalovirus viremia and bacterial necrotizing fasciitis complicated by septic shock.

LESSONS

(1) The steroid dose was difficult to titrate when AOSD complicated by sepsis. The differential diagnosis from MAS/HLH with bacterial/viral infection related severe sepsis was difficult but critical for decision making from clinicians and rheumatologists. (2) The conservative treatment with antibiotics for perforated appendix is safe but has a higher failure rate in immunocomprised patients such as systemic lupus erythematosus and AOSD. Early surgical intervention might contribute to better outcome. (3) The abdominal wall abscess can be spread from intra-abdominal lesion through the inferior epigastric vessels which were as weak points of abdominal wall. Imaging examinations contribute to acute diagnosis and help surgeons perform surgical interventions to prevent morbidity and mortality.

Quotidian High Spiking Fevers in Adult Still's Disease

BACKGROUND Adult Still's disease (ASD) is a rare systemic inflammatory condition, which commonly presents with the triad of quotidian fevers, rash, and non-specific rheumatologic symptoms such as myalgia and arthralgia. The etiology and pathogenesis are poorly understood and both the clinical presentation and laboratory data are typically nonspecific. As such, the presentation is often confused with infection, other autoimmune processes, and malignancy. CASE REPORT We present a case of a 29-year-old Hispanic female who presented with fever, sore throat, myalgia, and shortness of breath. Initially diagnosed with suspected pneumonia, extensive workup led to the final diagnosis of ASD due to the persistence of her symptoms, which met Yamaguchi Criteria, as well as exclusion of other possible etiologies. CONCLUSIONS ASD is a rare systemic inflammatory condition and its nonspecific presentation often leads to diagnostic delay and disease complications. We discuss the incidence, etiology, pathology, diagnosis, and standards in management of ASD. This case emphasizes the need for high clinical suspicion of ASD, and early exclusion of other etiologies, especially with failure of first-line treatment, to limit patient suffering and complications.