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Wu J, Sun L, Tang X, Zheng Q, Guo L, Xu L, Li Y, Lu M. Effective Therapy of Tocilizumab on Systemic Juvenile Idiopathic Arthritis Associated Refractory Macrophage Activation Syndrome. Mod Rheumatol 2021; 32:1114-1121. [PMID: 34971386 DOI: 10.1093/mr/roab119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/23/2021] [Accepted: 11/19/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To evaluate the safety and efficacy of tocilizumab (TCZ) on refractory macrophage activation syndrome (rMAS) associated with systemic juvenile idiopathic arthritis (sJIA-rMAS). METHODS We retrospectively reviewed the charts of 14 patients diagnosed with sJIA-rMAS, who were treated with TCZ after failing conventional therapies at three hospital centers from Jan 2016 to Dec 2020. Demographic, clinical, and laboratory characteristics were recorded at the onset of MAS, before TCZ (pre-TCZ) and 14 days after TCZ (post-TCZ). RESULTS The clinical manifestation of sJIA-rMAS included fever (100%), skin rashes (35.7%), lymphadenomegaly (42.9%), hepatomegaly (57.1%), splenomegaly (7.1%), gastrointestinal symptoms (28.6%), arthritis (14.3%), myalgia (28.6%) and polyserositis (14.3%). After TCZ treatment, fever (100%, 14/14), gastrointestinal symptoms (100%, 4/4) and myalgia (100%, 4/4) were significantly improved after one week (p< 0.05). Skin rashes, lymphadenomegaly and arthritis also improved in many patients but these parameters did not reach statistical significance. In post-TCZ group, decreases in levels of c-reactive protein, erythrocyte sedimentation rate and serum ferritin of sJIA-rMAS were observed compared with pre-TCZ (p< 0.05). Although not statistically significant, post-TCZ group showed normalization of white blood cell, platelet count, alanine aminotransferase, aspartate aminotransferase, lactic dehydrogenase and triglyceride levels compared with pre-TCZ. No disease relapse or fatality was recorded during the follow-up (25 months, range 3-60 months). CONCLUSIONS TCZ is safe and effective for the treatment of sJIA-rMAS after failure of conventional therapies.
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Affiliation(s)
- Jianqiang Wu
- Department of Rheumatology Immunology and Allergy, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Li Sun
- Department of Rheumatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Xuemei Tang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Qi Zheng
- Department of Rheumatology Immunology and Allergy, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Li Guo
- Department of Rheumatology Immunology and Allergy, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Li Xu
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yandie Li
- Department of Rheumatology Immunology and Allergy, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Meiping Lu
- Department of Rheumatology Immunology and Allergy, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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Bojan A, Parvu A, Zsoldos IA, Torok T, Farcas AD. Macrophage activation syndrome: A diagnostic challenge (Review). Exp Ther Med 2021; 22:904. [PMID: 34257717 PMCID: PMC8243343 DOI: 10.3892/etm.2021.10336] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/26/2021] [Indexed: 12/13/2022] Open
Abstract
Macrophage activation syndrome (MAS) represents an acute and severe inflammatory syndrome, idiopathic (primary) or secondary to infections, rheumatic diseases, malignancies, or drugs. MAS is underdiagnosed, being confused with sepsis, adverse effects of anti-arthritic drugs or exacerbated symptoms of evolving rheumatologic or infectious diseases. Because of the late diagnosis, most patients do not benefit from effective therapy, leading to death. Elucidation of valid early diagnostic criteria of MAS would be a particularly important step in reducing the mortality due to this pathology. Thus, the purpose of this review based on 40 studies centered on the diagnostic criteria of MAS. We detailed the main diagnostic criteria and the few diagnostic scores or sets of criteria that have been recently published. The criteria most frequently encountered in the literature include: Fever, hepatosplenomegaly, hyperferritinemia, hepatopathy, coagulopathy, thrombocytopenia, hypertriglyceridemia, decrease in erythrocyte sedimentation rate and bone marrow hemophagocytosis. The most elaborate diagnostic score will result following an ongoing international project and consensus, the Delphi International Survey.
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Affiliation(s)
- Anca Bojan
- Hematology Department, 'Iuliu Hatieganu' University of Medicine and Pharmacy, 400124 Cluj-Napoca, Romania.,Hematology Department, 'Prof. Dr. Ioan Chiricuta' Oncological Insitute, 400124 Cluj-Napoca, Romania
| | - Andrada Parvu
- Hematology Department, 'Iuliu Hatieganu' University of Medicine and Pharmacy, 400124 Cluj-Napoca, Romania.,Hematology Department, 'Prof. Dr. Ioan Chiricuta' Oncological Insitute, 400124 Cluj-Napoca, Romania
| | - Iulia-Andrea Zsoldos
- Hematology Department, 'Prof. Dr. Ioan Chiricuta' Oncological Insitute, 400124 Cluj-Napoca, Romania
| | - Tunde Torok
- Hematology Department, 'Iuliu Hatieganu' University of Medicine and Pharmacy, 400124 Cluj-Napoca, Romania.,Hematology Department, 'Prof. Dr. Ioan Chiricuta' Oncological Insitute, 400124 Cluj-Napoca, Romania
| | - Anca Daniela Farcas
- Internal Medicine Department, 'Iuliu Hatieganu' University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania.,Cardiology Department, Emergency County Clinic Hospital, 400006 Cluj-Napoca, Romania
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Abstract
Cyclosporine A, an inhibitor of calcineurin, exerts an immunomodulator action interfering with T cell activation. Even though novel therapeutic tools have emerged, CyA still represents a suitable option in several clinical rheumatology settings. This is the case of refractory nephritis and cytopenias associated with systemic lupus erythematosus. Furthermore, CyA is a valued therapeutic tool in the management of uveitis and thrombophlebitis in course of Behçet's disease. Topical CyA has been proven to be beneficial in the dry eye of Sjogren's syndrome, whereas oral treatment with CyA can be considered for the severe complications of adult onset Still's disease. CyA provides a therapeutic option in psoriatic arthritis, being rather effective in skin disease. CyA is currently regarded as a second-line option for patients with inflammatory myopathies refractory to standard regimen. CyA is used even in paediatric rheumatology, in particular in the management of juvenile dermatomyositis and macrophage activation syndrome associated with systemic juvenile idiopathic arthritis. Importantly, CyA has been shown to suppress the replication of HCV, and it can thus be safely prescribed to those patients with chronic hepatitis C. Noteworthy, CyA can be administered throughout the gestation course. Surely, caution should be paid to CyA safety profile, in particular to its nephrotoxicity. Even though most evidence comes from small and uncontrolled studies with few randomised controlled trials, CyA should be still regarded as a valid therapeutic tool in 2016 rheumatology.
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Shi L, Hu F, Xu C, Zhu H, Qie D, Yuan C, Tao Y, Liu H. Plasma exchange successfully treated macrophage activation syndrome in rheumatoid factor-positive polyarticular juvenile idiopathic arthritis with co-existing pneumonia. Int J Rheum Dis 2017; 21:1142-1145. [PMID: 28328098 DOI: 10.1111/1756-185x.13064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Macrophage activation syndrome (MAS) is one of the serious complications associated with rheumatic diseases, especially systemic juvenile idiopathic arthritis (sJIA). Here we describe a 9-year-old girl with rheumatoid factor (RF)-positive polyarticular JIA, not sJIA, combined with pneumonia who was successfully treated by plasma exchange. She was diagnosed with RF-positive polyarticular JIA based on positive RF and multiple joint swelling and tenderness 3 years ago. She was admitted in our hospital with myalgia for 2 days and a high fever for half a day. Physical examination revealed relapsing joints symptoms and rough breathing sounds of lungs. The laboratory examination showed increased liver enzymes, elevated serum ferritin and procalcitonin (PCT), decreased percentage of nature killer (NK) cells and fibrinogen, and activated macrophage phagocytosing hematopoietic elements in bone marrow. The elevated PCT and chest computed tomography scan confirmed she also had pneumonia. Intravenous methylprednisolone and oral cyclosporine A followed by intravenous immunoglobulin were added on the basis of antibiotics therapy, but clinical symptoms and laboratory findings did not improve. Finally, we changed to plasma exchange once every other day for a total of three times. Within 1 week, the girl recovered from the MAS completely.
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Affiliation(s)
- Lianjie Shi
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Fanlei Hu
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Chuanhui Xu
- Department of General Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Huaqun Zhu
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Di Qie
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Chuanjie Yuan
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Yuhong Tao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Hanmin Liu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
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Li L, Shi F, Li J, Huang Q, Xu C, Yang L, Yang Q, Shaikh F, Ye M. Immunoregulatory effect assessment of a novel melanin and its carboxymethyl derivative. Bioorg Med Chem Lett 2017; 27:1831-1834. [PMID: 28284807 DOI: 10.1016/j.bmcl.2017.02.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 02/16/2017] [Accepted: 02/17/2017] [Indexed: 10/20/2022]
Abstract
A novel melanin with low molecular weight (LIM205, 522Da) was isolated from the fermentation broth of Lachnum sp. and its carboxymethyl derivative (CLIM205) was prepared. The immunoregulatory effects of LIM205 and CLIM205 in immuno-compromised mice induced by cyclophosphamide were investigated. The results demonstrated that both LIM205 and CLIM205 could significantly increase the thymus and spleen indices, specific and nonspecific (including carbon clearance ability) immunity, humoral and cellular immunity of mice. Treatment with LIM205 and CLIM205 could increase activities of SOD, GSH-PX, CAT and decrease content of MDA in the mice. Furthermore, for all animal tests, the immunoregulatory activities of CLIM205 were more prominent than that of LIM205. In conclusion, our findings suggested that the natural products LIM205, as well as its carboxymethyl derivative CLIM205, had significant immunoregulatory activities, which might be a promising source of immunoregulator in healthcare field.
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Affiliation(s)
- Lan Li
- Microbial Resources and Application Laboratory, School of Food Science and Engineering, Hefei University of Technology, Hefei 230009, China
| | - Fang Shi
- Microbial Resources and Application Laboratory, School of Food Science and Engineering, Hefei University of Technology, Hefei 230009, China
| | - Jinglei Li
- Microbial Resources and Application Laboratory, School of Food Science and Engineering, Hefei University of Technology, Hefei 230009, China
| | - Qianli Huang
- School of Biological and Medical Engineering, Hefei University of Technology, Hefei 230009, China
| | - Can Xu
- Microbial Resources and Application Laboratory, School of Food Science and Engineering, Hefei University of Technology, Hefei 230009, China
| | - Liuqing Yang
- Microbial Resources and Application Laboratory, School of Food Science and Engineering, Hefei University of Technology, Hefei 230009, China
| | - Qinghua Yang
- School of Biological and Medical Engineering, Hefei University of Technology, Hefei 230009, China
| | - Farnaz Shaikh
- Microbial Resources and Application Laboratory, School of Food Science and Engineering, Hefei University of Technology, Hefei 230009, China
| | - Ming Ye
- Microbial Resources and Application Laboratory, School of Food Science and Engineering, Hefei University of Technology, Hefei 230009, China.
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John CC, Bingi KK, Brant RW, Costello LM, Livengood RH. An 18-year-old with recurrent Fever, night sweats, and lymphadenopathy. Macrophage activation syndrome. Pediatr Ann 2015; 44:146-8. [PMID: 25875979 DOI: 10.3928/00904481-20150410-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Suresh N, Sankar J. Macrophage activation syndrome: a rare complication of incomplete Kawasaki disease. ACTA ACUST UNITED AC 2013; 30:61-4. [DOI: 10.1179/146532810x12637745452239] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Vilaiyuk S, Sirachainan N, Wanitkun S, Pirojsakul K, Vaewpanich J. Recurrent macrophage activation syndrome as the primary manifestation in systemic lupus erythematosus and the benefit of serial ferritin measurements: a case-based review. Clin Rheumatol 2013; 32:899-904. [PMID: 23483294 DOI: 10.1007/s10067-013-2227-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 02/27/2013] [Indexed: 12/16/2022]
Abstract
Macrophage activation syndrome (MAS) is a fatal complication in rheumatic diseases. It is characterized by prolonged fever, pancytopenia, and hepatosplenomegaly, which are consequences of uncontrolled macrophage activation. MAS in children is most commonly associated with systemic juvenile idiopathic arthritis. Its association with systemic lupus erythematosus (SLE) is relatively rare, so we report a Thai boy who initially presented with MAS and eventually was diagnosed as having SLE. He also had recurrent MAS during the course of therapy. Hyperferritinemia is one of the abnormal laboratory findings in MAS and it has been used as an inflammatory marker. However, its correlation with disease activity remains unclear. Therefore, a review of literature regarding MAS-associated SLE in children and ferritin level in this disease was carried out.
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Affiliation(s)
- Soamarat Vilaiyuk
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Rachatevi, Bangkok 10400, Thailand.
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Shabbir M, Lucas J, Lazarchick J, Shirai K. Secondary hemophagocytic syndrome in adults: a case series of 18 patients in a single institution and a review of literature. Hematol Oncol 2010; 29:100-6. [PMID: 20809477 DOI: 10.1002/hon.960] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Accepted: 06/24/2010] [Indexed: 12/24/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is rare in adults and is usually fatal without treatment. We present a consecutive series of 18 adults with HLH diagnosed at our institution between 2004 and 2009. All diagnoses were confirmed by pathology. The median age at diagnosis was 56 years (range: 18-73 years), with a male: female ratio of 2:1. Patients uniformly presented with fever. Fifty-five per cent of the patients presented with evidence of hepatomegaly or splenomegaly. All of the patients had at least a bi- or trilineage cytopenia. Elevated liver enzymes, hyperferritinemia, hypertriglyceridemia and hyperfibrinogenemia were seen in 50, 100, 40 and 50% of patients, respectively. The presumed causes were as follows; haematological malignancies (n = 4), post-autologous stem cell transplant (n = 2), infection (n = 2), rheumatologic illness (n = 2), sickle cell disease (n = 1), post-orthotopic liver transplant (n = 1) and idiopathic (n = 3). The median time from suspicion to diagnosis was 5 days (1-27 days). Corticosteroids and/or cyclosporine were the most frequently used treatment regimen. Other agents used were etoposide, IVIG, cyclophosphamide and chemotherapy. The mortality rate was 72%, with multi-system organ failure being the most common cause of death. Median survival time from diagnosis was 35 days. Six patients are alive to date. In a univariate analysis, the presence of fever was the only factor that was statistically significant for predicting a poor prognosis (early mortality) (p = 0.05). In conclusion, a high index of suspicion is the critical factor for early diagnosis. Early treatment with immunosuppressant is warranted, and a thorough diagnostic evaluation to identify the underlying cause should be undertaken.
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Affiliation(s)
- Munira Shabbir
- Division of Hematology and Oncology, Medical University of South Carolina, Charleston, USA
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Chou RC, Dinarello CA, Ferry JA, Dal Cin P. A 36-year-old woman with recurrent high-grade fevers, hypotension, and hypertriglyceridemia. Arthritis Care Res (Hoboken) 2010; 62:128-36. [PMID: 20191502 DOI: 10.1002/acr.20024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Richard C Chou
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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