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Srkalovic G, Nijim S, Srkalovic MB, Fajgenbaum D. Increase in Vascular Endothelial Growth Factor (VEGF) Expression and the Pathogenesis of iMCD-TAFRO. Biomedicines 2024; 12:1328. [PMID: 38927535 DOI: 10.3390/biomedicines12061328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/31/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
TAFRO (thrombocytopenia (T), anasarca (A), fever (F), reticulin fibrosis (F/R), renal failure (R), and organomegaly (O)) is a heterogeneous clinical subtype of idiopathic multicentric Castleman disease (iMCD) associated with a significantly poorer prognosis than other subtypes of iMCD. TAFRO symptomatology can also be seen in pathological contexts outside of iMCD, but it is unclear if those cases should be considered representative of a different disease entity or simply a severe presentation of other infectious, malignant, and rheumatological diseases. While interleukin-6 (IL-6) is an established driver of iMCD-TAFRO pathogenesis in a subset of patients, the etiology is unknown. Recent case reports and literature reviews on TAFRO patients suggest that vascular endothelial growth factor (VEGF), and the interplay of VEGF and IL-6 in concert, rather than IL-6 as a single cytokine, may be drivers for iMCD-TAFRO pathophysiology, especially renal injury. In this review, we discuss the possible role of VEGF in the pathophysiology and clinical manifestations of iMCD-TAFRO. In particular, VEGF may be involved in iMCD-TAFRO pathology through its ability to activate RAS/RAF/MEK/ERK and PI3K/AKT/mTOR signaling pathways. Further elucidating a role for the VEGF-IL-6 axis and additional disease drivers may shed light on therapeutic options for the treatment of TAFRO patients who do not respond to, or otherwise relapse following, treatment with IL-6 targeting drugs. This review investigates the potential role of VEGF in the pathophysiology of iMCD-TAFRO and the potential for targeting related signaling pathways in the future.
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Affiliation(s)
- Gordan Srkalovic
- Herbert-Herman Cancer Center, University of Michigan Health-Sparrow, Lansing, MI 48912, USA
| | - Sally Nijim
- Center for Cytokine Storm Treatment & Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | | | - David Fajgenbaum
- Center for Cytokine Storm Treatment & Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Shirakashi M, Nishida Y, Nakashima R, Fujimoto M, Hiwa R, Tsuji H, Kitagori K, Akizuki S, Morinobu A, Yoshifuji H. TAFRO syndrome is associated with anti-SSA/Ro60 antibodies, in contrast to idiopathic castleman disease. Sci Rep 2024; 14:2889. [PMID: 38311632 PMCID: PMC10838910 DOI: 10.1038/s41598-024-53413-5] [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: 07/04/2023] [Accepted: 01/31/2024] [Indexed: 02/06/2024] Open
Abstract
TAFRO syndrome is an acute systemic inflammatory disease characterized by thrombocytopenia, anasarca, fever, reticulin fibrosis/renal dysfunction, and organomegaly. There have been increasing reports that TAFRO is a disease distinct from idiopathic multicentric Castleman disease and that TAFRO patients may be positive for anti-SSA antibodies. To assess anti-SSA antibody positivity and the clinical characteristics of the two diseases, we retrospectively compared 7 TAFRO and 10 iMCD patients in our hospital. The mean age of onset of TAFRO and iMCD was 48.0 (interquartile range [IQR], 41-53) and 45.0 (IQR, 35-53) years, respectively. The TAFRO and iMCD groups had 6 (86%) and 4 (40%) male patients, respectively, and the following pretreatment laboratory values: platelet count, 3.8 (IQR, 2.2-6.4) and 35.5 (IQR, 22.2-42.8) × 104/μL, respectively; C-reactive protein, 10.2 (IQR, 6.8-21.4) and 9.5 (IQR, 6.2-13.6) mg/dL, respectively; IgG, 1431 (IQR, 1112-1815) and 4725 (IQR, 3755-5121) mg/dL, respectively. RNA immunoprecipitation (5 cases for anti-SSA) or protein array (5 cases for anti-SSA/Ro60) detected anti-SSA antibodies in six (86%) TAFRO patients but not in iMCD patients; it did not detect anti-SSB antibodies in any of the patients. None of the patients were diagnosed with Sjögren syndrome. All iMCD patients treated with tocilizumab (TCZ) responded well. Meanwhile, two of six TAFRO patients treated with TCZ showed inadequate responses; thus, both patients were switched to rituximab, following which they achieved remission. TAFRO and iMCD have different clinical features. TAFRO may be categorized as a severe phenotype of the anti-SSA antibody syndrome.
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Affiliation(s)
- Mirei Shirakashi
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yuri Nishida
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Ran Nakashima
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Masakazu Fujimoto
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryosuke Hiwa
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hideaki Tsuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Koji Kitagori
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shuji Akizuki
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
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Wu X, Zhang X, Qian S, Shi C, Li X, Feng X, Zhu L, Ge J, Li Z, Zhang M. The experience of diagnosis and treatment for TAFRO syndrome. Ann Hematol 2023; 102:3515-3520. [PMID: 37713125 DOI: 10.1007/s00277-023-05435-8] [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: 04/12/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023]
Abstract
Early identification, diagnosis and treatment of TAFRO syndrome are very importants. We retrospectively analysed 6 patients with TAFRO syndrome. Their clinical manifestations, treatment methods, survival and other aspects were summarized. All patients were pathologically diagnosed with Castleman's disease, with fever, an inflammatory storm state and varying degrees of anasarca. All patients received steroid therapy; four of them also received chemotherapy, and 1 received rituximab. Of the 3 patients with severe disease, only 1 patient who received the recommended dose of glucocorticoids survived. Early administration of glucocorticoids can improve the prognosis, especially in patients with severe disease, and adequate glucocorticoids are important.
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Affiliation(s)
- Xiaolong Wu
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
- Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, 450052, Henan, People's Republic of China
| | - Xudong Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
- Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, 450052, Henan, People's Republic of China
| | - Siyu Qian
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
- Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, 450052, Henan, People's Republic of China
| | - Cunzhen Shi
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
- Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, 450052, Henan, People's Republic of China
| | - Xin Li
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
- Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, 450052, Henan, People's Republic of China
| | - Xiaoyan Feng
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
- Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, 450052, Henan, People's Republic of China
| | - Linan Zhu
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
- Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, 450052, Henan, People's Republic of China
| | - Jingjing Ge
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
- Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, 450052, Henan, People's Republic of China
| | - Zhaoming Li
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
- Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, 450052, Henan, People's Republic of China
| | - Mingzhi Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China.
- Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, 450052, Henan, People's Republic of China.
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Sato H, Kanno A, Sato M, Endo A, Ito H, Ohara T, Shirota Y, Sumitomo K, Mori T, Furukawa K. Case Report: A case of TAFRO syndrome with severe and prolonged thrombocytopenia: diagnostic pitfalls. Front Immunol 2023; 14:1266187. [PMID: 37901232 PMCID: PMC10611515 DOI: 10.3389/fimmu.2023.1266187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Thrombocytopenia, anasarca, myelofibrosis, renal dysfunction, and organomegaly (TAFRO) syndrome is a rare condition with diverse clinical and pathological characteristics related to multi-organ damage. We report a case of TAFRO syndrome complicated by immune thrombocytopenia with prolonged fever and thrombocytopenia for several weeks. A 61-year-old man was transferred with sepsis caused by Enterococcus faecalis, and developed disseminated intravascular coagulation. Antibiotics treatment was initiated: however, low-grade fever and thrombocytopenia persisted despite the adequate antimicrobial treatment. Systemic edema, pleural effusion, and ascites had developed before hospitalization, and renal and liver function had deteriorated, resulting in progressive multi-organ damage. Prednisolone 40 mg/day was initiated based on the assumption of a condition in which excessive production of inflammatory cytokines would lead to systemic deterioration and fatal organ damage. Subsequently, the fever resolved, and renal function began to normalize. However, thrombocytopenia did not show much recovery trend after Helicobacter pylori eradication therapy and initiation of thrombopoietin receptor agonists. Bone marrow biopsy results showed normal bone marrow with no malignant findings. Alternatively, significant clinical signs met the diagnostic criteria for TAFRO syndrome, and a renal biopsy revealed thrombotic microangiopathy, which is also reasonable for renal involvement in TAFRO syndrome. The use of cyclosporine remarkably corrected the thrombocytopenia. We considered this a case of TAFRO syndrome that developed after sepsis with disseminated intravascular coagulation and performed the differential diagnosis of prolonged thrombocytopenia and excluded it. Although TAFRO syndrome is a unique disease concept, diagnostic criteria may consist of nonspecific elements such as generalized edema, thrombocytopenia, persistent fever, and elevated inflammatory response, and there are many differential conditions to exclude, requiring caution in diagnosing TAFRO syndrome.
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Affiliation(s)
- Hironori Sato
- Division of Geriatric and Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Atsuhiro Kanno
- Division of Geriatric and Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Minato Sato
- Division of Geriatric and Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Akari Endo
- Division of Nephrology and Endocrinology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Hiroki Ito
- Division of Nephrology and Endocrinology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Takahiro Ohara
- Division of Geriatric and Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yuko Shirota
- Division of Hematology and Rheumatology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kazuhiro Sumitomo
- Department of Community and General Medicine, Tohoku Medical and Pharmaceutical University, Wakabayashi Hospital, Sendai, Japan
| | - Takefumi Mori
- Division of Nephrology and Endocrinology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Katsutoshi Furukawa
- Division of Geriatric and Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
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Peng Q, Wu F, Shi Y, Wang J, Zhai Z, Wang Z. Idiopathic multicentric castleman's disease mimicking immunoglobulin G4-related disease responding well to Bortezomib: a case report. BMC Nephrol 2023; 24:290. [PMID: 37784011 PMCID: PMC10546740 DOI: 10.1186/s12882-023-03335-7] [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: 05/09/2023] [Accepted: 09/18/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Castleman's disease (CD) is a rare disease that has clinical and pathological similarities to lymphoma and is characterized by a high frequency of associated immunological dysfunction. ImmunoglobulinG4-related disease (IgG4-RD) is a collection of systemic disorders that affect numerous organs and are also referred to as IgG4-associated sclerosing diseases. CD and IgG4-RD are difficult to separate because they may manifest similar commin clinical features. CASE PRESENTATION This case describes a 53-year-old female who, during routine medical check-up, exhibited a progressive increase in serum globulin levels and a simultaneous worsening of anemia symptoms, raising concern for a clonal plasma cell disease such as myeloma. However, bone marrow punctures did not reveal any abnormal plasma cells. Also, serum and urine immunofixation electrophoresis demonstrated no abnormal monoclonal protein bands. In addition, several laboratory findings excluded chronic liver disease, chronic infections caused by bacteria or viruses. Later, we found elevated serum IgG4 levels (10,700 mg/L), and identified multiple enlarged lymph nodes throughout the patient's body. Axillary lymph node aspiration revealed no abnormal lymphocytes, ruling out the possibility of lymphoma. Pathological morphology of the axillary lymph revealed a large number of plasma cells in the lymphatic follicles. In addition, there was a reduction in lymphatic follicle size and apoptosis of the germinal centres. Immunohistochemistry revealed IgG4+/IgG + in > 40% of cells, and more than 100 IgG4 + cells per high powered field (HPF) of specimen. As of now, finding strongly suggested IgG4-RD. This patient was treated with glucocorticoids and various immunosuppressive drugs, such as prednisone, cyclosporine, methotrexate, cyclophosphamide, mycophenolate mofetil, azathioprine and hydroxychloroquine. Unfortunately, the patient did not recover. Ultimately, idiopathic multicentric Castleman disease (iMCD) was diagnosed in relation to the patient's clinical presentation and laboratory tests, and after combination chemotherapy (VCD: Bortezomib, Cyclophosphamide and Dexamethasone), durable remission was achieved without serious adverse effects. During the follow-up period of one year and ten months, the patient remained stable. CONCLUSION The diagnosis of Castleman must be distinguished from other disorders such as IgG4-RD, malignant lymphoma, reactive hyperplasia of various lymph nodes (mostly caused by viral infections), plasmacytoma, advanced HIV and rheumatic diseases. Besides observing systemic symptoms, laboratory tests such as immunoglobulin levels, complement levels, interleukin levels, and C-reactive protein levels should also be performed in order to determine a diagnosis.
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Affiliation(s)
- Qian Peng
- Department of Hematology/Hematological Lab, Second Hospital of Anhui Medical University, Hefei, 230601, China
| | - Fan Wu
- Department of Hematology/Hematological Lab, Second Hospital of Anhui Medical University, Hefei, 230601, China
| | - Yuting Shi
- Department of Radiology, Second Hospital of Anhui Medical University, Hefei, 230601, China
| | - Juan Wang
- Department of Hematology/Hematological Lab, Second Hospital of Anhui Medical University, Hefei, 230601, China
| | - Zhimin Zhai
- Department of Hematology/Hematological Lab, Second Hospital of Anhui Medical University, Hefei, 230601, China
| | - Zhitao Wang
- Department of Hematology/Hematological Lab, Second Hospital of Anhui Medical University, Hefei, 230601, China.
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Yamamoto S, Wells K, Morita K, Tanigaki K, Muro K, Matsumoto M, Nakai H, Arai Y, Akizuki S, Takahashi K, Minamiguchi S, Fukuma S, Yanagita M. Severe TAFRO Syndrome Mimicking Hepatorenal Syndrome Successfully Treated with a Multidisciplinary Approach: A Case Report and Literature Review. Intern Med 2023; 62:2715-2724. [PMID: 36725034 PMCID: PMC10569924 DOI: 10.2169/internalmedicine.1178-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/19/2022] [Indexed: 02/03/2023] Open
Abstract
Finding the ideal balance between efficacy and safety of immunosuppression is challenging, particularly in cases of severe TAFRO syndrome. We herein report a 60-year-old man diagnosed with grade 5 TAFRO syndrome mimicking hepatorenal syndrome that was successfully treated by glucocorticoid, tocilizumab, and cyclosporin despite virus infection. Furthermore, by examining 14 peer-reviewed remission cases, we revealed that the recovery periods among inflammation, renal dysfunction, and thrombocytopenia were quite different, with recovery from thrombocytopenia notably slow. All patients requiring dialysis were successfully withdrawn from dialysis, and the reversibility from kidney injury was good. This clinical information will help clinicians plan treatments and tailor the intensity of immunosuppression.
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Affiliation(s)
- Shinya Yamamoto
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
| | - Ken Wells
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
| | - Keisuke Morita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
| | - Katsuya Tanigaki
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
- Department of Nephrology, Kansai Denryoku Hospital, Japan
| | - Koji Muro
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
| | - Minami Matsumoto
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
| | - Hirotsugu Nakai
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Japan
- Department of Radiology, Tenri Hospital, Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Japan
| | - Shuji Akizuki
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Japan
| | - Ken Takahashi
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Japan
| | - Sachiko Minamiguchi
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, Japan
| | - Shingo Fukuma
- Human and Health Sciences, Graduate School of Medicine, Kyoto University, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
- Institute for the Advanced Study of Human Biology (WPI-ASHBi), Kyoto University, Japan
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Cordero L, Aguilar-Rodríguez F, Sandino J, Alonso M, Gutiérrez E. Siltuximab Monotherapy in Tafro Syndrome: A Case Report and Review of the Literature. J Nephrol 2023; 36:1181-1185. [PMID: 36652167 DOI: 10.1007/s40620-022-01517-4] [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: 08/04/2022] [Accepted: 10/25/2022] [Indexed: 01/19/2023]
Abstract
TAFRO syndrome is characterized by the presence of thrombocytopenia, anasarca, fever, reticular myelofibrosis, organomegaly, and is frequently associated with kidney damage in the form of membranoproliferative glomerulonephritis (MPGN) or thrombotic microangiopathy (TMA). Treatment is based on corticosteroids. A 59-year-old man who suffered from heart disease, pancytopenia and hepatosplenomegaly of unknown etiology developed nephrotic syndrome and progressive renal insufficiency, with a kidney biopsy suggestive of MPGN with a "full-house" immunofluorescence pattern. Positron emission tomography (PET) revealed multiple lymphadenopathies which histologically were compatible with multicentric Castleman's disease. The patient was diagnosed with TAFRO syndrome and treatment with siltuximab was started, with evident improvement at 3 months. TAFRO syndrome is a rare entity which may present with severe kidney involvement and histological findings of MPGN or TMA, with or without immune complex deposits. Our case suggests that a corticosteroid-free regimen with siltuximab could be an attractive therapeutic option.
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Affiliation(s)
- Lucía Cordero
- Department of Nephrology, Hospital Universitario, 12 de Octubre, Av. Córdoba Km 5.400, 28041, Madrid, Spain
| | | | - Justo Sandino
- Department of Nephrology, Hospital Universitario, 12 de Octubre, Av. Córdoba Km 5.400, 28041, Madrid, Spain.,Instituto de Investigación del Hospital Universitario, 12 de Octubre (imas12), Madrid, Spain
| | - Marina Alonso
- Department of Pathology, University Hospital, 12 de Octubre, Madrid, Spain
| | - Eduardo Gutiérrez
- Department of Nephrology, Hospital Universitario, 12 de Octubre, Av. Córdoba Km 5.400, 28041, Madrid, Spain. .,Instituto de Investigación del Hospital Universitario, 12 de Octubre (imas12), Madrid, Spain.
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González García A, Fernández-Martín J, Robles Marhuenda Á. Idiopathic multicentric Castleman disease and associated autoimmune and autoinflammatory conditions: practical guidance for diagnosis. Rheumatology (Oxford) 2022; 62:1426-1435. [PMID: 35997567 PMCID: PMC10070070 DOI: 10.1093/rheumatology/keac481] [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: 06/30/2022] [Revised: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
Idiopathic multicentric Castleman disease (iMCD) is an infrequent and life-threatening disorder characterised by systemic inflammatory symptoms, generalised lymphadenopathy, polyclonal lymphocyte proliferation, and organ dysfunction caused by a hyperinflammatory state. It accounts for one third to one half of all multicentric Castleman disease (MCD) cases. iMCD is often associated with autoimmune manifestations that may precede the iMCD diagnosis, be identified at the same time or follow it. In addition, iMCD may also coincide with a number of autoimmune diseases (such as psoriasis or myasthenia gravis) or autoinflammatory diseases (such as familial Mediterranean fever). Moreover, diverse inflammatory disorders, such as rheumatoid arthritis, systemic lupus erythematosus, adult-onset Still disease, systemic juvenile idiopathic arthritis, immunoglobulin (IgG4) related disease, or the recently described VEXAS syndrome, can present clinical features or lymphadenopathy with histopathological "Castleman-like" findings compatible with those of iMCD. Given the iMCD clinical heterogeneity and the overlap with other autoimmune or autoinflammatory disorders, iMCD diagnosis can be challenging. In this review, we explore the overlap between iMCD and inflammatory diseases and provide practical guidance on iMCD diagnosis in order to avoid misdiagnosis and confusion with other autoimmune or autoinflammatory conditions.
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Affiliation(s)
- Andrés González García
- Systemic Autoimmune and Orphan Diseases Unit, Department of Internal Medicine, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Julián Fernández-Martín
- Internal Medicine Department, Hospital Álvaro Cunqueiro, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Ángel Robles Marhuenda
- Autoimmune Diseases Unit of the Internal Medicine Service, Hospital La Paz, Madrid, Spain
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To and TAFRO - a cryptic cause of acute renal failure: a case report. BMC Nephrol 2022; 23:19. [PMID: 34991522 PMCID: PMC8740417 DOI: 10.1186/s12882-022-02660-7] [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: 09/30/2021] [Accepted: 12/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background TAFRO syndrome is a rare clinical subtype of idiopathic multicentric Castlemans disease characterised by thrombocytopenia, anasarca, myelofibrosis, renal dysfunction, and organomegaly. Renal involvement is common, sometimes requiring temporary renal replacement therapy. Due to the associated thrombocytopenia, renal biopsies are rarely performed limiting descriptions of the renal histopathology in this condition. This case describes a patient with TAFRO syndrome and the associated renal histology. Case presentation A 49-year-old Caucasian man presented to a tertiary hospital in Sydney with a six- week history of malaise, non-bloody diarrhoea, progressive shortness of breath, and drenching night sweats. A progressive bicytopenia and renal function decline necessitating temporary dialysis prompted a bone marrow aspirate and trephine, as well as a renal biopsy respectively. This noted a hypercellular bone marrow with increased granulopoiesis, reduced erythropoiesis, and fibrosis, with renal histology suggesting a thrombotic microangiopathic-like glomerulopathy. Alternate conditions were excluded, and a diagnosis of TAFRO syndrome was made. Glucocorticoids and rituximab were initiated with rapid renal recovery, and normalisation of his haematologic parameters achieved at six months. Conclusion This case describes an atypical thrombotic microangiopathy as the predominant histologic renal lesion in a patient with TAFRO syndrome. This was responsive to immunosuppression with glucocorticoids and rituximab, highlighting the importance of early recognition of this rarely described condition.
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Nagai M, Uchida T, Yamada M, Komatsu S, Ota K, Mukae M, Iwamoto H, Hirano H, Karube M, Kaname S, Oda T. TAFRO Syndrome in a Kidney Transplant Recipient That Was Diagnosed on Autopsy: A Case Report. Front Med (Lausanne) 2021; 8:747678. [PMID: 34671626 PMCID: PMC8520974 DOI: 10.3389/fmed.2021.747678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/06/2021] [Indexed: 01/09/2023] Open
Abstract
A 57-year-old man who received a kidney transplant 4 years previously owing to unknown underlying disease presented with thrombocytopenia and fever. Hepatosplenomegaly and lymphadenopathy were observed, and development of prominent anasarca and worsening of renal function yielded the diagnosis of TAFRO syndrome. He was treated with high-dose steroids and plasmapheresis, and a thrombopoietin receptor agonist was administered for refractory thrombocytopenia. However, his general condition worsened, and he died on day 92. Histopathological analysis of a kidney autopsy specimen showed thrombotic microangiopathy characterized by glomerular endothelial swelling, mesangiolysis, and double contours of the glomerular capillary walls. His bone marrow showed megakaryocytic hyperplasia with mild reticulin fibrosis. Interestingly, these clinical and pathological features were remarkably similar to those the patient demonstrated before the kidney transplant, suggesting the recurrence of TAFRO syndrome. TAFRO syndrome is a rare systemic disorder whose concept has recently been established, but information on its long-term outcome is scarce. To our knowledge, this is the first case of TAFRO syndrome developing in a kidney transplant recipient, which suggests that disease recurrence occurs many years after the kidney transplant.
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Affiliation(s)
- Marie Nagai
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Takahiro Uchida
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Muneharu Yamada
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Shuuhei Komatsu
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Kohei Ota
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Mitsuya Mukae
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Hitoshi Iwamoto
- Department of Kidney Transplantation Surgery, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Hiroshi Hirano
- Departmet of Diagnostic Pathology, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Miho Karube
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Shinya Kaname
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
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Tu KH, Fan PY, Chen TD, Chuang WY, Wu CY, Ku CL, Tian YC, Yang CW, Fang JT, Yang HY. TAFRO Syndrome with Renal Thrombotic Microangiopathy: Insights into the Molecular Mechanism and Treatment Opportunities. Int J Mol Sci 2021; 22:ijms22126286. [PMID: 34208103 PMCID: PMC8230834 DOI: 10.3390/ijms22126286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/12/2021] [Accepted: 05/19/2021] [Indexed: 01/02/2023] Open
Abstract
TAFRO syndrome is an extremely rare form of idiopathic MCD, characterized by thrombocytopenia, anasarca, fever, reticulin fibrosis on bone marrow biopsy, and organomegaly. Like idiopathic MCD, renal involvement is also a common presentation in patients with TAFRO syndrome. Furthermore, membranoproliferative glomerulonephritis (MPGN)-like injury and thrombotic microangiopathy (TMA) are the most reported histopathologic findings of renal biopsy. Several molecular mechanisms have been previously postulated in order to explain the TAFRO syndrome symptoms, including abnormal production of interleukin-6 (IL-6), vascular endothelial growth factor (VEGF), etc. The role of these cytokines in renal injury, however, is not well understood. The aim of this review article is to summarize the latest knowledge of molecular mechanisms behind the TAFRO syndrome and their potential role in renal damage.
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Affiliation(s)
- Kun-Hua Tu
- Kidney Research Center, Department of Nephrology, Chang-Gung Memorial Hospital, Taoyuan 333, Taiwan; (K.-H.T.); (P.-Y.F.); (Y.-C.T.); (C.-W.Y.); (J.-T.F.)
- Transplantation Immunology Lab, Chang-Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Pei-Yi Fan
- Kidney Research Center, Department of Nephrology, Chang-Gung Memorial Hospital, Taoyuan 333, Taiwan; (K.-H.T.); (P.-Y.F.); (Y.-C.T.); (C.-W.Y.); (J.-T.F.)
| | - Tai-Di Chen
- Department of Pathology, Chang-Gung Memorial Hospital, Taoyuan 333, Taiwan; (T.-D.C.); (W.-Y.C.)
| | - Wen-Yu Chuang
- Department of Pathology, Chang-Gung Memorial Hospital, Taoyuan 333, Taiwan; (T.-D.C.); (W.-Y.C.)
- College of Medicine, Chang-Gang University, Taoyuan 333, Taiwan;
| | - Chao-Yi Wu
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang-Gung Memorial Hospital, Taoyuan 333, Taiwan;
| | - Cheng-Lung Ku
- College of Medicine, Chang-Gang University, Taoyuan 333, Taiwan;
| | - Ya-Chung Tian
- Kidney Research Center, Department of Nephrology, Chang-Gung Memorial Hospital, Taoyuan 333, Taiwan; (K.-H.T.); (P.-Y.F.); (Y.-C.T.); (C.-W.Y.); (J.-T.F.)
- Transplantation Immunology Lab, Chang-Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chih-Wei Yang
- Kidney Research Center, Department of Nephrology, Chang-Gung Memorial Hospital, Taoyuan 333, Taiwan; (K.-H.T.); (P.-Y.F.); (Y.-C.T.); (C.-W.Y.); (J.-T.F.)
- College of Medicine, Chang-Gang University, Taoyuan 333, Taiwan;
| | - Ji-Tseng Fang
- Kidney Research Center, Department of Nephrology, Chang-Gung Memorial Hospital, Taoyuan 333, Taiwan; (K.-H.T.); (P.-Y.F.); (Y.-C.T.); (C.-W.Y.); (J.-T.F.)
- College of Medicine, Chang-Gang University, Taoyuan 333, Taiwan;
| | - Huang-Yu Yang
- Kidney Research Center, Department of Nephrology, Chang-Gung Memorial Hospital, Taoyuan 333, Taiwan; (K.-H.T.); (P.-Y.F.); (Y.-C.T.); (C.-W.Y.); (J.-T.F.)
- Transplantation Immunology Lab, Chang-Gung Memorial Hospital, Taoyuan 333, Taiwan
- Advanced Immunology Lab, Chang-Gung Memorial Hospital, Taoyuan 333, Taiwan
- Correspondence: ; Tel.: +886-3328-1200-8181
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12
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Membranous nephropathy associated with multicentric Castleman's disease that was successfully treated with tocilizumab: a case report and review of the literature. BMC Nephrol 2021; 22:216. [PMID: 34107915 PMCID: PMC8191014 DOI: 10.1186/s12882-021-02423-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 06/03/2021] [Indexed: 12/14/2022] Open
Abstract
Background Multicentric Castleman’s disease is a life-threatening disorder involving a systemic inflammatory response and multiple organ failure caused by the overproduction of interleukin-6. Although renal complications of Castleman’s disease include AA amyloidosis, thrombotic microangiopathy, and membranoproliferative glomerulonephritis, membranous nephropathy is relatively rare. We experienced a case of secondary membranous nephropathy associated with Castleman’s disease. Case presentation The patient was a 43-year-old Japanese man who had shown a high zinc sulfate value in turbidity test, polyclonal hypergammaglobulinemia, anemia, and proteinuria. A physical examination revealed diffuse lymphadenopathy, an enlarged spleen and papulae of the body trunk. A skin biopsy of a papule on the patient’s back showed plasma cells in the perivascular area and he was diagnosed with multicentric Castleman’s disease, plasma cell variant. Kidney biopsy showed the appearance of bubbling in the glomerular basement membranes in Periodic acid methenamine silver stain and electron microscopy revealed electron dense deposits within and outside the glomerular basement membranes. Since immunofluorescence study showed predominant granular deposition of IgG1 and IgG2, he was diagnosed with secondary membranous nephropathy associated with Castleman’s disease. He was initially treated with prednisolone alone, however his biochemical abnormalities did not improve. After intravenous tocilizumab (700 mg every 2 weeks) was started, his C-reactive protein elevation, anemia, and polyclonal gammopathy improved. Furthermore, his urinary protein level declined from 1.58 g/gCr to 0.13 g/gCr. The prednisolone dose was gradually tapered, then discontinued. He has been stable without a recurrence of proteinuria for more than 6 months. Conclusions Tocilizumab might be a treatment option for secondary membranous nephropathy associated with Castleman’s disease.
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Shibata S, Tabata S, Morita H, Endo T, Kawasaki N, Okamoto Y, Inano S, Takiuchi Y, Fukunaga A, Kitano T. Borderline Case of TAFRO Syndrome and POEMS Syndrome. Intern Med 2021; 60:1589-1595. [PMID: 33328401 PMCID: PMC8188039 DOI: 10.2169/internalmedicine.5860-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
TAFRO syndrome and POEMS syndrome are lymphoproliferative disorders with elevated interleukin-6 and vascular endothelial growth factor (VEGF) levels; however, their underlying pathogenic mechanisms remain unclear. Similarities have been reported in the pathological findings of the lymph nodes of TAFRO syndrome, Multicentric Castleman disease (MCD), and some cases of POEMS syndrome. However, there is no consensus on the relationship among them. We encountered a case of lymphoproliferative disorder that presented with manifestations of both TAFRO syndrome and POEMS syndrome. This case may be a subtype of idiopathic MCD and will be very important for establishing the disease concept of TAFRO syndrome and POEMS syndrome.
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Affiliation(s)
- Sho Shibata
- Department of Hematology, Tazuke Kofukai, Medical Research Institute, Kitano Hospital, Japan
| | - Sumie Tabata
- Department of Hematology, Tazuke Kofukai, Medical Research Institute, Kitano Hospital, Japan
| | - Hajime Morita
- Department of Nephrology, Tazuke Kofukai, Medical Research Institute, Kitano Hospital, Japan
| | - Tomomi Endo
- Department of Nephrology, Tazuke Kofukai, Medical Research Institute, Kitano Hospital, Japan
| | - Naoto Kawasaki
- Department of Hematology, Tazuke Kofukai, Medical Research Institute, Kitano Hospital, Japan
| | - Yoshio Okamoto
- Department of Hematology, Tazuke Kofukai, Medical Research Institute, Kitano Hospital, Japan
| | - Shojiro Inano
- Department of Hematology, Tazuke Kofukai, Medical Research Institute, Kitano Hospital, Japan
| | - Yoko Takiuchi
- Department of Hematology, Tazuke Kofukai, Medical Research Institute, Kitano Hospital, Japan
| | - Akiko Fukunaga
- Department of Hematology, Tazuke Kofukai, Medical Research Institute, Kitano Hospital, Japan
| | - Toshiyuki Kitano
- Department of Hematology, Tazuke Kofukai, Medical Research Institute, Kitano Hospital, Japan
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14
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Kawabata H, Fujimoto S, Sakai T, Yanagisawa H, Kitawaki T, Nara K, Hagihara M, Yamamoto H, Tanimizu M, Kato C, Origuchi T, Sunami K, Sunami Y, Masunari T, Nakamura N, Kobayashi M, Yamagami K, Miura K, Takai K, Aoki S, Tsukamoto N, Masaki Y. Patient's age and D-dimer levels predict the prognosis in patients with TAFRO syndrome. Int J Hematol 2021; 114:179-188. [PMID: 33929719 PMCID: PMC8085640 DOI: 10.1007/s12185-021-03159-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 11/26/2022]
Abstract
Objectives To identify prognostic factors for TAFRO syndrome, a rare inflammatory disorder of unknown etiology characterized by thrombocytopenia, anasarca, fever, reticulin myelofibrosis, renal dysfunction, and organomegaly. Methods Data of patients with TAFRO syndrome were extracted from a Japanese patient registry. Patients were divided into groups according to the clinical and laboratory parameters at initial presentation. Cut-off values for the laboratory parameters were determined using receiver operating characteristic curve analysis and by clinical relevance. Patient survival was analyzed by the Kaplan–Meier method. Univariable analysis was performed using log-rank tests. Multivariable analyses were performed with the logistic regression model and the Cox proportional hazards model. Results We extracted the data of 83 patients with TAFRO syndrome from the registry. Univariable analysis identified several potential prognostic factors. Of these factors, age ≥60 years and D-dimer ≥18 μg/dL remained significant predictors of poor overall survival in the multivariable Cox proportional hazards model. Based on these results, we developed a simple prognostic scoring system for TAFRO syndrome (TS-PSS). Conclusion Patients in our cohort were stratified into low, intermediate, and high-risk groups by the TS-PSS. This system should be verified with independent patient cohorts in future studies. Supplementary Information The online version contains supplementary material available at 10.1007/s12185-021-03159-x.
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Affiliation(s)
- Hiroshi Kawabata
- Department of Hematology and Immunology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Ishikawa-ken, 920-0293, Japan.
| | - Shino Fujimoto
- Department of Hematology and Immunology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Ishikawa-ken, 920-0293, Japan
| | - Tomoyuki Sakai
- Department of Hematology and Immunology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Ishikawa-ken, 920-0293, Japan
| | - Hiroto Yanagisawa
- Department of Hematology and Immunology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Ishikawa-ken, 920-0293, Japan
| | - Toshio Kitawaki
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenji Nara
- Department of Hematology, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Masao Hagihara
- Department of Hematology, Eiju General Hospital, Tokyo, Japan
| | - Hiroshi Yamamoto
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masakuni Tanimizu
- Department of Internal Medicine, Tottori Municipal Hospital, Tottori, Japan
| | - Chikako Kato
- Department of General Internal Medicine, Toyota Kosei Hospital, Toyota, Japan
| | - Tomoki Origuchi
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Kazutaka Sunami
- Department of Hematology, NHO Okayama Medical Center, Okayama, Japan
| | - Yoshitaka Sunami
- Department of Hematology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Taro Masunari
- Department of Infectious Disease, Chugoku Central Hospital, Fukuyama, Japan
| | - Nobuhiko Nakamura
- Department of Hematology, Gifu University Graduate School of Medicine, Gifu, Japan
| | | | - Keiko Yamagami
- Department of Internal Medicine, Osaka City General Hospital, Osaka, Japan
| | - Katsuhiro Miura
- Division of Hematology and Rheumatology, Department of Internal Medicine, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Kazue Takai
- Department of Hematology, Niigata City General Hospital, Niigata, Japan
| | - Sadao Aoki
- Department of Pathophysiology, Faculty of Pharmaceutical Sciences, Niigata University of Pharmacy and Applied Life Sciences, Niigata, Japan
| | | | - Yasufumi Masaki
- Department of Hematology and Immunology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Ishikawa-ken, 920-0293, Japan
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15
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Sato T, Ono Y, Matsushima J, Fujii A, Sato Y, Hidaka Y, Kawamoto S, Yoshino A, Takeda T, Ueda Y, Ban S. Histopathologic findings of TAFRO syndrome with immunohistochemical analysis of the kidney specimen: A case report. HUMAN PATHOLOGY: CASE REPORTS 2021. [DOI: 10.1016/j.ehpc.2020.200471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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16
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Shimada K, Sasaki T, Okabe M, Koike K, Takahashi D, Terashima R, Honda Y, Matsumoto N, Fukui A, Ishikawa M, Tsuboi N, Yokoo T. TAFRO Syndrome With Kidney Involvement: A Case Series of Patients With Kidney Biopsies. Kidney Med 2021; 3:286-293. [PMID: 33851125 PMCID: PMC8039406 DOI: 10.1016/j.xkme.2020.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
TAFRO (thrombocytopenia, anasarca, fever, reticulin myelofibrosis/renal insufficiency, and organomegaly) syndrome is a systemic inflammatory disease sharing some features with Castleman disease and POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes) syndrome in relation to abnormal secretions of interleukin 6 and vascular endothelial growth factor. The kidney is a main target organ of TAFRO syndrome but the kidney histopathology associated with TAFRO syndrome is yet to be completely defined. We report 3 TAFRO syndrome cases with different clinical courses in which kidney biopsies were performed. In all 3 cases, kidney biopsies showed similar glomerular lesions of diffuse global swelling of the endothelium and expansion of subendothelial spaces, consistent with severe glomerular endothelial injury. Case 3 showed an additional finding of focal tubulointerstitial injury characterized by marked plasma cell infiltration, which was absent in the other 2 cases. Clinical symptoms in cases 1 and 2, which had lower disease severity scores of TAFRO syndrome, were effectively treated with the administration of corticosteroids or a combination of corticosteroids and cyclosporine A. Case 3, with a higher disease severity score, had an aggressive clinical course that was refractory to corticosteroids and tocilizumab; the patient ultimately died of multiple organ failure. In all 3 cases, kidney biopsy provided indications for the diagnosis process and clinical management of TAFRO syndrome.
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Affiliation(s)
- Keiki Shimada
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.,Department of Nephrology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Takaya Sasaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.,Department of Nephrology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Masahiro Okabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kentaro Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Daisuke Takahashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Risa Terashima
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yu Honda
- Department of Nephrology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Naoto Matsumoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Fukui
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Masahiro Ishikawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.,Department of Nephrology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Tosaki T, Okabe M, Suzuki T, Shimizu A, Koike K, Tsuboi N, Kawamura T, Ohashi R, Yano S, Yokoo T. Membranous nephropathy with thrombotic microangiopathy-like lesions successfully treated with tocilizumab in a patient with idiopathic multicentric Castleman disease. CEN Case Rep 2021; 10:265-272. [PMID: 33389670 DOI: 10.1007/s13730-020-00559-6] [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: 07/26/2020] [Accepted: 11/09/2020] [Indexed: 01/13/2023] Open
Abstract
Idiopathic multicentric Castleman disease (iMCD) is a systemic lymphoproliferative disease involving multiple organs, including the kidneys. Membranous nephropathy (MN) has been rarely reported as a complication of iMCD. We herein report the case of a 48-year-old man with a 9-year history of iMCD that was complicated by treatment-resistant nephrotic syndrome due to MN. The first renal biopsy performed at the age of 45 years showed diffuse and global MN with a mild glomerular endothelial injury. He was treated with combined therapy of corticosteroids, immunosuppressants, and tocilizumab, an anti-interleukin-6 (IL-6) receptor monoclonal antibody, which was administered every 2-3 weeks. However, nephrotic syndrome persisted, and renal impairment slowly worsened. Serial biopsy performed at 3 years after the first biopsy confirmed advanced lesions of both MN-related and glomerular endothelial injuries. Modification of the therapeutic strategy to weekly administration of tocilizumab gradually led to the remission of proteinuria, allowing the termination of corticosteroids. Thus, the present case suggests a close link between excessive IL-6 actions and the development of glomerular lesions in iMCD. Successful treatment by strict inhibition of IL-6 actions, in this case, may provide a clue for deciding the therapeutic strategy for severe renal complications associated with iMCD.
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Affiliation(s)
- Takeshi Tosaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan
| | - Masahiro Okabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan.
| | - Tomo Suzuki
- Department of Nephrology, Kameda Medical Center, Kamogawa, Japan.,Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Akihiro Shimizu
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan
| | - Kentaro Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan
| | - Tetsuya Kawamura
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan
| | - Ryuji Ohashi
- Department of Diagnostic Pathology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan
| | - Shingo Yano
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, Japan
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Minamikawa S, Matsumura O, Sato S, Nakagishi Y, Tanaka R. A pediatric case of tocilizumab-resistant TAFRO syndrome treated successfully with rituximab. Pediatr Blood Cancer 2020; 67:e28489. [PMID: 32568456 DOI: 10.1002/pbc.28489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/17/2020] [Accepted: 05/24/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Shogo Minamikawa
- Department of General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan.,Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Osamu Matsumura
- Department of General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Seiko Sato
- Department of General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Yasuo Nakagishi
- Department of General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Ryojiro Tanaka
- Department of General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
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19
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Zhou Q, Zhang Y, Zhou G, Zhu J. Kidney biopsy findings in two patients with TAFRO syndrome: case presentations and review of the literature. BMC Nephrol 2020; 21:499. [PMID: 33225930 PMCID: PMC7682079 DOI: 10.1186/s12882-020-02119-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 10/21/2020] [Indexed: 01/09/2023] Open
Abstract
Background TAFRO syndrome is a clinical subtype of idiopathic multicentric Castleman disease (iMCD) that is characterized by thrombocytopenia, anasarca, fever, reticulin myelofibrosis (or renal dysfunction), and organomegaly. TAFRO syndrome has only recently been described, and many clinicians are unaware of this disease, leading to delays in diagnosis and treatment. We present two patients with TAFRO syndrome in whom renal biopsies were performed. Case presentation Both patients had subacute onset and exhibited renal insufficiency, edema, anemia, thrombocytopenia, polyserositis and lymphadenopathy over the disease course. However, there were many differences in their clinical manifestations. Case 1 was a 30-year-old woman admitted due to intermittent vaginal bleeding for 3 weeks. Laboratory tests on admission showed severe renal insufficiency (creatinine: 624 μmol/L), severe anemia (Hb: 41 g/L), and moderate thrombocytopenia (61 × 109/L). Case 2 was a 42-year-old man. Acute epigastric pain was his initial complaint, and computed tomography (CT) revealed retroperitoneal exudation around the pancreas. He was diagnosed with acute pancreatitis, and after treatment with a proton pump inhibitor (PPI) and somatostatin, his abdominal pain still recurred. During treatment, renal failure gradually increased, with oliguria, fever, anemia, thrombocytopenia, edema and massive ascites. Lymph node histologies were consistent with the hyaline-vascular (HV) type and mixed type, respectively, and renal histopathologies were consistent with thrombotic microangiopathy (TMA)-like renal lesions and membranoproliferative glomerulonephritis (MPGN), respectively. Their general conditions improved after glucocorticoid therapy, but their renal functions did not recover completely. On the basis of glucocorticoids, second-line treatments with tocilizumab and rituximab, respectively, were applied. Conclusions The diagnosis of TAFRO syndrome is based mainly on clinical manifestations and lymph node biopsies. A reliable early diagnosis and appropriate rapid treatment are essential to improve patient outcomes. Clinicians should deepen their understanding of this disease and similar conditions. Once the disease is suspected, lymph node biopsies should be performed as soon as possible. In addition, renal biopsies should be actively performed in patients with renal involvement.
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Affiliation(s)
- Qianyun Zhou
- Intensive Care Unit Peking University Shougang Hospital, Beijing, China. .,Department of Emergency, Peking University People's Hospital, Beijing, China.
| | - Yuanyuan Zhang
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Guangping Zhou
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Jihong Zhu
- Department of Emergency, Peking University People's Hospital, Beijing, China
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20
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[TAFRO syndrome and cutaneous necrotizing vasculitis]. Rev Med Interne 2020; 42:134-139. [PMID: 33218790 DOI: 10.1016/j.revmed.2020.10.384] [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: 04/21/2020] [Revised: 10/02/2020] [Accepted: 10/28/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION TAFRO syndrome is a systemic inflammatory syndrome in the spectrum of Castleman's disease, associating thrombocytopenia, anasarca, fever, renal failure and/or reticulin myelofibrosis and organomegaly. Its association with necrotizing cutaneous vasculitis has not yet been reported. CASE REPORT A 69-year-old woman presented with weight loss, fever, anasarca, organomegaly, lymphadenopathy, anuria and extensive necrotic livedo occurring after acute diarrhea. Biology showed anemia, thrombocytopenia, renal failure, hypergammaglobulinemia, a circulating B-lymphocyte clone, hypoparathyroidism and autoimmune hypothyroidism. The skin biopsy showed small vessel vasculitis with fibrinoid necrosis. Methylprednisolone infusions associated with tocilizumab were ineffective and the patient became anuric. Rituximab and plasma exchanges associated to corticosteroids allowed remission for 2 months. Combination of rituximab, cyclophosphamide and dexamethasone resulted in a prolonged remission. CONCLUSION We report here the first case of severe cutaneous necrotizing vasculitis in a patient suffering from TAFRO syndrome. The possible resistance to tocilizumab should be known.
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Xia P, Zhang L, Zou M, Zhang T, Li R, Shi X, Wang J, Qin Y, Li X, Li J, Chen L. Acute Kidney Injury Caused by TAFRO Syndrome in a Chinese Patient: Efficacy of Long-Term Corticosteroids Combined with Bortezomib and Cyclophosphamide. Kidney Blood Press Res 2020; 45:623-630. [PMID: 32492687 DOI: 10.1159/000505458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 12/15/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Thrombocytopenia, ascites, myelofibrosis, renal dysfunction, and organomegaly (TAFRO) syndrome is a newly recognized and rare clinical subtype of Castleman disease. Renal involvement in TAFRO syndrome usually presents with mild proteinuria, microscopic hematuria, and acute renal injury requiring temporary renal replacement. There is no standard therapy available and treatment failures are common, leading to a poor prognosis. We report a case of acute renal failure caused by TAFRO syndrome, successfully managed by long-term corticosteroids combined with bortezomib and cyclophosphamide. CASE PRESENTATION The patient was a 52-year-old female who presented with fever, anasarca, oliguria, and abdominal distension at first. She progressed rapidly to anuric renal failure requiring hemodialysis. She also demonstrated thrombocytopenia, anemia, coagulopathy, and a hyperinflammatory status. Her CT scan showed severe polyserositis, splenomegaly, and lymphadenopathy. Her serum vascular epithelial growth factor level was significantly elevated. Axillary lymph node biopsy showed hyaline-vascular type Castleman disease, supporting the diagnosis of TAFRO syndrome. Her renal function recovered after high-dose steroids and supportive treatment. A weekly dosing regimen of bortezomib, cyclophosphamide, and dexamethasone combined with medium dose prednisone in between were deployed. Her blood cell count and renal function remained stable after 6 months. The inflammation was suppressed and the polyserositis resolved completely. CONCLUSION TAFRO syndrome is rare and has a poor prognosis due to the lack of standard treatment. Our patient might be the first TAFRO case successfully treated by bortezomib, cyclophosphamide, and corticosteroids.
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Affiliation(s)
- Peng Xia
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Lu Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Menglian Zou
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Tengyue Zhang
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ran Li
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoxiao Shi
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Wang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Qin
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jian Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Limeng Chen
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China,
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Computed tomography findings of early-stage TAFRO syndrome and associated adrenal abnormalities. Eur Radiol 2020; 30:5588-5598. [PMID: 32440781 DOI: 10.1007/s00330-020-06919-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/22/2020] [Accepted: 04/24/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To compare CT findings of early (within 3 weeks post-onset)- and later (within 1 month before or after diagnostic criteria were satisfied, and later than 3 weeks post-onset) stage thrombocytopenia, anasarca, fever, reticulin fibrosis, renal dysfunction, and organomegaly (TAFRO) syndrome. METHODS Between 2014 and 2019, 13 patients with TAFRO syndrome (8 men and 5 women; mean age, 54.9 years) from nine hospitals were enrolled. The number of the following CT findings (CT factors) was recorded: the presence of anasarca, organomegaly, adrenal ischaemia, anterior mediastinal lesion, bony lesion, and lymphadenopathy. Records of adrenal disorders (adrenomegaly, ischaemia, and haemorrhage) throughout the disease course were also collected. Differences in CT factors at each stage were statistically compared between remission and deceased groups. RESULTS Para-aortic oedema and mild lymphadenopathy were observed in all patients, whereas pleural effusion, ascites, and subcutaneous oedema were found in 5/13, 7/13, and 7/13 cases, respectively, at the early stage. CT factors at the early stage were significantly higher in the deceased than in the remission group (mean, 11 vs 6.5; p = 0.04), while they were nonsignificant at the later stage. Adrenal disorders were present in 7/13 cases throughout the course including 6 of adrenomegaly and 4 of ischaemia at the early stage. CONCLUSIONS Para-aortic oedema and mild lymphadenopathy are most common at the early stage. Anasarca, organomegaly, lymphadenopathy, and adrenal disorders on early-stage CT are useful for unfavourable prognosis prediction. Moreover, adrenal disorders are frequent even at the early stage and are useful for early diagnosis of TAFRO syndrome. KEY POINTS • CT findings facilitate early diagnosis and prognosis prediction in TAFRO syndrome. • Adrenal disorders are frequently observed in TAFRO syndrome. • Adrenal disorders are useful for differential diagnosis of TAFRO syndrome.
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