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Nakamura Y, Kato N, Tatematsu Y, Arai Y, Mori N, Shibata K, Yamazaki M, Yasui H, Fujiwara S, Yamakawa T, Maruyama S. Clinical characteristics of anti-GBM disease with thrombotic microangiopathy: a case report and literature review. CEN Case Rep 2024; 13:37-44. [PMID: 37213063 PMCID: PMC10201029 DOI: 10.1007/s13730-023-00797-4] [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: 12/22/2022] [Accepted: 05/12/2023] [Indexed: 05/23/2023] Open
Abstract
The coexistence of anti-glomerular basement membrane (anti-GBM) disease with thrombotic microangiopathy (TMA) is rarely encountered, and the clinical characteristics of this phenomenon are not well known.A 76-year-old Japanese woman with a history of idiopathic pulmonary disease was diagnosed with anti-GBM disease due to rapidly progressive glomerulonephritis and a positive anti-GBM antibody test result. We treated the patient with hemodialysis, glucocorticoids, and plasmapheresis. During treatment, the patient suddenly became comatose. TMA was then diagnosed because of thrombocytopenia and microangiopathic hemolytic anemia. The activity of a disintegrin-like and metalloproteinase with thrombospondin type 1 motif 13 (ADAMTS-13) was retained at 48%. Although we continued the treatment, the patient died of respiratory failure. An autopsy revealed the cause of respiratory failure to be an acute exacerbation of interstitial pneumonia. The clinical findings of the renal specimen indicated anti-GBM disease; however, there were no lesions suggestive of TMA. A genetic test did not reveal an apparent genetic mutation of the atypical hemolytic uremic syndrome.We conducted a literature review of past case reports of anti-GBM disease with TMA. The following clinical characteristics were obtained. First, 75% of the cases were reported in Asia. Second, TMA tended to appear during the treatment course for anti-GBM disease and usually resolved within 12 weeks. Third, ADAMTS-13 activity was retained above 10% in 90% of the cases. Fourth, central nervous system manifestations occurred in more than half of the patients. Fifth, the renal outcome was very poor. Further studies are required to understand the pathophysiology of this phenomenon.
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Affiliation(s)
- Yoshihiro Nakamura
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan.
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan.
| | - Noritoshi Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Yoshitaka Tatematsu
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Yoshifumi Arai
- Department of Pathology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Nozomi Mori
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Katsuaki Shibata
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Michiko Yamazaki
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Hirotoshi Yasui
- Department of Respiratory Medicine, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Shinji Fujiwara
- Department of Hematology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Taishi Yamakawa
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
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Yang S, Zhou J. Systemic lupus erythematosus and antineutrocytic cytoplasmic antibody-associated vasculitis overlap syndrome presenting mainly with alveolar hemorrhage: A case report and literature review. Medicine (Baltimore) 2023; 102:e36356. [PMID: 38050315 PMCID: PMC10695521 DOI: 10.1097/md.0000000000036356] [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: 07/13/2023] [Accepted: 09/22/2023] [Indexed: 12/06/2023] Open
Abstract
RATIONALE Systemic lupus erythematosus (SLE) and anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) are 2 different diseases that can manifest in the same person, which are known as SLE/AAV overlap syndrome. This overlap syndrome is difficult to diagnose, a high rate of missed diagnosis and misdiagnosis, and a poor prognosis. PATIENT CONCERNS A 52-year-old woman was diagnosed with SLE in 2019. She was readmitted to our hospital in October 2021 because of abdominal pain and melasma for 10 days. DIAGNOSES She had positive anti-dsDNA, decreased complement C3 and C4, fever, polyarthralgia, and hemolytic anemia. She was diagnosed as microscopic polyangiitis according to the American College of Rheumatology 2022 AAV classification criteria (she had 4 items: no nasal lesions, eosinophils < 1 × 109, negative c/PR3-ANCA antibodies, and positive p-ANCA antibodies. The score was 6 points). INTERVENTIONS The patient was treated with methylprednisolone 200 mg and cyclophosphamide 0.2 g immunosuppressive therapy. OUTCOMES After 2 months of follow-up, the patient's symptoms, including abdominal pain, melena, hematuria, and hemoptysis, resolved completely. And she underwent a reexamination of chest computed tomography and the results showed the previous exudation had been absorbed. LESSONS AAV should be considered in lupus patients with the above symptoms, especially the progressive decrease of hemoglobin. Relevant examinations are needed to confirm the diagnosis. Early diagnosis and accurate treatment of SLE/AAV overlap syndrome are beneficial to patients' better prognosis and control the treatment cost.
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Affiliation(s)
- Siyu Yang
- School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, China
- Rheumatology Department, The Second People’s Hospital of Yibin City, Yibin, China
| | - Jin Zhou
- School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, China
- Rheumatology Department, The Second People’s Hospital of Yibin City, Yibin, China
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3
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Cohen J. Vasculitis and Other Immunologically Mediated Diseases. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00085-x] [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: 10/21/2022] Open
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Systematic Review of Diffuse Alveolar Hemorrhage in Systemic Lupus Erythematosus: Focus on Outcome and Therapy. J Clin Rheumatol 2016; 21:305-10. [PMID: 26308350 DOI: 10.1097/rhu.0000000000000291] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is an uncommon but potentially life-threatening manifestation of systemic lupus erythematosus (SLE) associated with high mortality. Although survival and its associated clinical, laboratory, and therapeutic features have been reported for case reports and series, they have not been systematically reviewed. OBJECTIVES The purpose of this systematic review was to assess survival of episodes of DAH in SLE over 3 decades and to categorize trends in therapies, commonly utilized to treat this disorder. RESULTS Overall, SLE patients survived 61% of 174 DAH episodes representing 140 patients. Episode survival was 67% in the time period from 2000 to 2013. Corticosteroids were nearly universally used therapeutically, and cyclophosphamide was used in 55%. Plasmapheresis was used in 31% and did not appear to be associated with survival. CONCLUSIONS Diffuse alveolar hemorrhage in SLE still carries a high risk of mortality; however, survival trends appear to demonstrate an increase from approximately 25% in the 1980s to 67% in the current decade. Increased use of cyclophosphamide appears to be associated with better survival, whereas plasmapheresis does not appear to influence outcome. Although these results need to be interpreted with caution because they are not derived from randomized controlled trials, we believe this represents the largest reported compilation of survival data in DAH associated with SLE.
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Jarrot PA, Chiche L, Hervier B, Daniel L, Vuiblet V, Bardin N, Bertin D, Terrier B, Amoura Z, Andrés E, Rondeau E, Hamidou M, Pennaforte JL, Halfon P, Daugas E, Dussol B, Puéchal X, Kaplanski G, Jourde-Chiche N. Systemic Lupus Erythematosus and Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Overlap Syndrome in Patients With Biopsy-Proven Glomerulonephritis. Medicine (Baltimore) 2016; 95:e3748. [PMID: 27258503 PMCID: PMC4900711 DOI: 10.1097/md.0000000000003748] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The aim of the study was to report the clinical, biological, and pathological characteristics of patients with glomerulonephritis (GN) secondary to systemic lupus erythematosus (SLE)/antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) overlap syndrome.A nationwide survey was conducted to identify cases of SLE/AAV overlap syndrome. Data were collected from SLE and AAV French research groups. Inclusion criteria were diagnosis of both SLE and AAV according to international classification criteria and biopsy-proven GN between 1995 and 2014. Additional cases were identified through a systematic literature review. A cohort of consecutive biopsy-proven GN was used to study the prevalence of overlapping antibodies and/or overlap syndrome.The national survey identified 8 cases of SLE/AAV overlap syndrome. All patients were female; median age was 40 years. AAV occurred before SLE (n = 3), after (n = 3), or concomitantly (n = 2). Six patients had rapidly progressive GN and 3/8 had alveolar hemorrhage. All patients had antinuclear antibodies (ANA); 7/8 had p-ANCA antimyeloperoxidase (MPO) antibodies. Renal biopsies showed lupus nephritis (LN) or pauci-immune GN. Remission was obtained in 4/8 patients. A literature review identified 31 additional cases with a similarly severe presentation. In the GN cohort, ANCA positivity was found in 30% of LN, ANA positivity in 52% of pauci-immune GN, with no correlation with pathological findings. The estimated prevalence for SLE/AAV overlap syndrome was 2/101 (2%).In patients with GN, SLE/AAV overlap syndrome may occur but with a low prevalence. Most patients have an aggressive renal presentation, with usually both ANA and anti-MPO antibodies. Further studies are needed to assess shared pathogenesis and therapeutic options.
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Affiliation(s)
- Pierre-Andre Jarrot
- From the Department of Internal Medicine and Clinical Immunology (PAJ, GK), AP-HM Hôpital de La Conception; Inserm UMR-S 1076 Vascular Research Center of Marseille (PAJ, GK, NJ-C), Aix-Marseille Université; Department of Internal Medicine (LC, PH), Hôpital Européen de Marseille, Marseille; Reference Center for Systemic Lupus Erythematosus (BH, ZA), Department of Internal Medicine, AP-HP Hôpital Pitie-Salpêtrière, Paris; Department of Pathology (LD), AP-HM Hôpital de La Timone, Aix-Marseille Université; Department of Pathology (VV), Paul Bouin Laboratory, Reims, France; Laboratory of Immunology (NB, DB), AP-HM Hôpital de la Conception, Aix-Marseille Université, Marseille; French Vasculitis Study Group (BT, XP), Department of Internal Medicine, National Reference Center for Necrotizing Vasculitis, AP-HP Hôpital Cochin, University Paris-Descartes; Department of Internal Medicine (EA), Hôpital Civil, Strasbourg; Department of Nephrology (ER), AP-HP Hôpital Tenon, Paris; Department of Internal Medicine (MH), Hôpital Hôtel-Dieu, Nantes; Department of Internal Medicine (J-LP), Hôpital Robert Debré, Reims Université, Reims; Groupe Coopératif sur le Lupus Rénal (ED), Department of Nephrology, AP-HP Hôpital Bichat, Paris; and Department of Nephrology (BD, NJ-C), AP-HM Hôpital Conception, Aix-Marseille Université, Marseille, France
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Parrot A, Fartoukh M, Cadranel J. Hémorragie intra-alvéolaire. Rev Mal Respir 2015; 32:394-412. [DOI: 10.1016/j.rmr.2014.11.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 06/06/2014] [Indexed: 10/24/2022]
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7
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Goodpasture's syndrome: A clinical update. Autoimmun Rev 2015; 14:246-53. [DOI: 10.1016/j.autrev.2014.11.006] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 11/09/2014] [Indexed: 11/22/2022]
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8
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Manenti L, Gnappi E, Vaglio A, Allegri L, Noris M, Bresin E, Pilato FP, Valoti E, Pasquali S, Buzio C. Atypical haemolytic uraemic syndrome with underlying glomerulopathies. A case series and a review of the literature. Nephrol Dial Transplant 2013; 28:2246-59. [DOI: 10.1093/ndt/gft220] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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9
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Yamato K, Ishii T, Kawamura T. Microscopic polyangiitis in a girl with severe anemia and no respiratory symptoms. Pediatr Int 2012; 54:541-3. [PMID: 22830542 DOI: 10.1111/j.1442-200x.2011.03503.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
ANCA-positive microscopic polyangiitis is a rare in children. We reported an 11-year-old girl without respiratory symptoms with sever anemia which shows signs of hemolytic anemia in test data. Chest X-ray and computed tomography scans suggested alveolar hemorrhage. The patent developed night hypoxia and moderate proteinuria. Serum MPO-antibody was highly positive and renal biopsy demonstrated segmental necrosis or crescent formation. A diagnosis of microscopic polyangiitis was made. She responded to pulsed methylprednisolon and pulsed Endoxan therapy. Microscopic polyangitiis should be considered early in the differential diagnosis of patients presenting with anemia of an unknown origin.
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Affiliation(s)
- Kazumi Yamato
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan.
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Kim JJ, Park JK, Wang YP, Park HJ, Sung SW, Kim DY. Diffuse Alveolar Hemorrhage in a 39-year-old Woman: Unusual Initial Presentation of Microscopic Polyangiitis. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2011; 44:448-51. [PMID: 22324034 PMCID: PMC3270291 DOI: 10.5090/kjtcs.2011.44.6.448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2011] [Revised: 07/19/2011] [Accepted: 08/24/2011] [Indexed: 11/16/2022]
Abstract
Microscopic polyangiitis (MPA) is a necrotizing vasculitis involving the small vessels without granulomatous inflammation. Most MPA initially presents with renal involvement without pulmonary involvement. Isolated and initially presenting alveolar hemorrhage is very rare. The patient was a 39-year-old female with a progressive cough, dyspnea, and blood-tinged sputum for the previous 5 days. We determined that her condition was MPA though VATS lung biopsy and renal biopsy. After 2 months of steroid therapy, the chest lesions had improved. We report here a rare case of MPA with isolated and initial involvement of the lung with a review of the literature.
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Affiliation(s)
- Jae Jun Kim
- Department of Thoracic and Cardiovascular Surgery, St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Korea
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11
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Hervier B, Hamidou M, Haroche J, Durant C, Mathian A, Amoura Z. Systemic lupus erythematosus associated with ANCA-associated vasculitis: an overlapping syndrome? Rheumatol Int 2011; 32:3285-90. [PMID: 21805174 DOI: 10.1007/s00296-011-2055-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 07/10/2011] [Indexed: 01/12/2023]
Abstract
Systemic lupus erythematosus (SLE) and small-sized vessel vasculitis are usually two distinguishable autoimmune diseases. However, a vasculitis may be found in the course SLE but rarely corresponds to an ANCA-associated vasculitis (AAV). We report four cases of de novo SLE associated with AAV, our aim being to discuss the clinical significance of this association. We included four patients fulfilling the criteria for both SLE and AAV and followed in two different university hospitals between 1996 and 2009. In light of a 20-year literature review (25 described clinical cases), we discussed the etiopathogeny of such an association. All patients presented a severe renal involvement (creatininemia ranging from 120 to 370 μmol/l) and thrombopenia (ranging from 45,000 to 137,000 platelets/mm(3)). The other main clinical symptoms were arthritis (n = 3), serositis (n = 2) and intra-alveolar hemorrhage (n = 2). An inflammatory syndrome was noticed at diagnosis in all cases. ANCAs were MPO-ANCAs in all cases. Two out of these four patients were also diagnosed with antiphospholipid syndrome. The frequency of this association seems not fortuitous. Although the etiopathogenic mechanisms of such an association remain to be more precisely described, several clinical, histological and immunological features support the hypothesis of the existence of a SLE-AAV overlapping syndrome. Moreover, clinicians must be aware of such an overlapping syndrome, notably because its initial presentation can be very severe.
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Affiliation(s)
- B Hervier
- Internal Medicine Department, National Reference Centre for Lupus and Antiphospholipid Syndrome, CHU Pitié-Salpétrière, 83 Boulevard de l'hôpital, 75013 Paris, France.
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12
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An autopsy case of unexpected sudden death due to rupture of a thoracic aortic aneurysm into the left lung. Leg Med (Tokyo) 2011; 13:201-4. [DOI: 10.1016/j.legalmed.2011.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 02/01/2011] [Accepted: 02/01/2011] [Indexed: 11/19/2022]
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13
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Isono M, Araki H, Haitani T, Morita Y, Yasuda M, Kato N, Urasaki K, Tsujimura Y. Diffuse alveolar hemorrhage in lupus nephritis complicated by microscopic polyangiitis. Clin Exp Nephrol 2011; 15:294-8. [PMID: 21225308 DOI: 10.1007/s10157-010-0394-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Accepted: 12/08/2010] [Indexed: 11/30/2022]
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare but fatal complication in patients with systemic lupus erythematosus (SLE). We describe a case of a 74-year-old woman who presented with DAH as an initial presentation of SLE. She also had microscopic polyangiitis clinically manifesting as crescentic glomerulonephritis and purpura with positive myeloperoxidase (MPO)-antineutrophil cytoplasmic antibodies (ANCA). The patient transiently improved when treated with plasma exchange and methylprednisolone pulse therapy; however, she died of recurrent pulmonary hemorrhage and concurrent cryptococcal pneumonia. This case indicates that MPO-ANCA is associated with severe organ involvement such as pulmonary hemorrhage and crescentic glomerulonephritis in SLE.
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Affiliation(s)
- Motohide Isono
- Department of Medicine, Otsu Municipal Hospital, Otsu, Shiga 520-0804, Japan.
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Ishikawa T, Pollak S, Perdekamp MG, Thierauf A, Maeda H. Hemorrhage from a cavernous hemangioma with fatal blood aspiration: A rare cause of sudden unexpected death. Leg Med (Tokyo) 2010; 12:308-12. [DOI: 10.1016/j.legalmed.2010.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Revised: 06/15/2010] [Accepted: 06/20/2010] [Indexed: 02/07/2023]
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Watanabe H, Kitagawa W, Suzuki K, Yoshino M, Aoyama R, Miura N, Nishikawa K, Imai H. Thrombotic thrombocytopenic purpura in a patient with rapidly progressive glomerulonephritis with both anti-glomerular basement membrane antibodies and myeloperoxidase anti-neutrophil cytoplasmic antibodies. Clin Exp Nephrol 2010; 14:598-601. [DOI: 10.1007/s10157-010-0312-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Accepted: 06/09/2010] [Indexed: 10/19/2022]
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