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Garcia-Villanueva MJ, Garrote-Corral S, Pego-Reigosa JM, Jiménez Otero N, Uriarte Isazelaia E, Olivé Marqué A, Sangüesa Gómez C, Freire González M, Aurrecoechea Aguinaga E, Raya Álvarez E, Tomero Muriel E, Montilla Morales C, Galindo Izquierdo M, Calvo-Alén J, Menor-Almagro R, Serrano Benavente B, Martinez-Barrio J, Hernández-Beriain JA, Ibañez Barceló M, Bonilla Hernan G, Rosas J, Salgado Pérez E, Fernández-Nebro A, Rua-Figueroa I. Diffuse alveolar hemorrhage in patients with systemic lupus erythematosus: data from the Spanish society of rheumathology Lupus Register (RELESSER). Rheumatol Int 2024:10.1007/s00296-024-05684-4. [PMID: 39180523 DOI: 10.1007/s00296-024-05684-4] [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: 02/07/2024] [Accepted: 05/25/2024] [Indexed: 08/26/2024]
Abstract
INTRODUCTION Diffuse alveolar hemorrhage (DAH) is a rare complication with high mortality in patients with systemic lupus erythematosus (SLE). Early diagnosis and treatment are essential to improve patient prognosis. To determine the characteristics of patients with DAH and their mortality in a Spanish cohort of patients with SLE. METHODS Patients from the RELESSER (Spanish Society of Rheumatology Lupus Register) who had had at least one confirmed episode of DAH were included. Epidemiological, clinical, and laboratory characteristics were analyzed. RESULTS 4024 patients were included in the RELESSER register, 37 (0.9%), had at least one recorded episode of DAH. Only further data for 14 patients could be analyzed. In total, 92.9% were women, and for 4 (28.6%) DAH coincided with the debut of SLE. More than 80% of patients had renal involvement and thrombocytopenia. The most frequent manifestations were dyspnea (85.7%) and hypoxemia (100%), with the classic triad of hemoptysis, anemia and pulmonary infiltrates, appearing in 6 (46.2%) patients. The most frequently used treatments were glucocorticoids (85.7%) and cyclophosphamide (69.2%); plasmapheresis was utilized in 5 patients (35.7%) and 8, (57.1%) received intravenous immunoglobulins; 12 (85.7%) patients required admission to the ICU and 5 (35.7%) died. Tobacco use, history of lupus nephritis (LN), concomitant infection, and treatment with cyclophosphamide were more frequent in patients who died. CONCLUSIONS DAH is rare in patients with SLE; in up to one-third of patients, it may appear at the onset of the disease. Some factors, such as smoking, a history of LN, treatment with cyclophosphamide, or concomitant infection, are more prevalent in patients with an unfavorable outcome.
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Affiliation(s)
| | - Sandra Garrote-Corral
- Rheumatology Department, Hospital Universitario Ramón y Cajal, M-607, 9, 100, Madrid, 28034, Spain
| | - Jose María Pego-Reigosa
- Rheumatology Department, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
- IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases)-VIGO Group, Galicia Sur Health Research Institute, Vigo, Spain
| | - Norman Jiménez Otero
- IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases)-VIGO Group, Galicia Sur Health Research Institute, Vigo, Spain
| | | | | | - Clara Sangüesa Gómez
- Rheumatology Department, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Mercedes Freire González
- Rheumatology Department, Hospital Juan Canalejo, Hospital Universitario de A Coruña, Coruña, Spain
| | | | | | - Eva Tomero Muriel
- Rheumatology Department, Hospital Universitario la Princesa, Madrid, Spain
| | | | | | - Jaime Calvo-Alén
- Rheumatology Department, Hospital Universitario Araba, Vitoria, Spain
| | - Raúl Menor-Almagro
- Rheumatology Department Hospital Jerez de la Frontera, Jerez de la Frontera, Spain
| | | | | | | | | | | | - Jose Rosas
- Rheumatology Department, Hospital Marina Baixa, Villajoyosa, Alicante, Spain
| | - Eva Salgado Pérez
- Rheumatology Department, Complejo Hospitalario Universitario de Orense, Orense, Spain
| | - Antonio Fernández-Nebro
- Rheumatology Department, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
| | - Iñigo Rua-Figueroa
- Rheumatology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
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Bendstrup E, Lynn E, Troldborg A. Systemic Lupus Erythematosus-related Lung Disease. Semin Respir Crit Care Med 2024; 45:386-396. [PMID: 38547915 DOI: 10.1055/s-0044-1782653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
Systemic Lupus Erythematosus (SLE) is a multifaceted, multisystem autoimmune disorder with diverse clinical expressions. While prevalence reports vary widely, pulmonary involvement accounts for significant morbidity and mortality in SLE. This comprehensive review explores the spectrum of pulmonary disease in SLE, including upper airway manifestations (e.g., laryngeal affection), lower airway conditions (e.g., bronchitis, bronchiolitis, bronchiectasis), parenchymal diseases (e.g., interstitial lung disease, acute lupus pneumonitis, diffuse alveolar hemorrhage), pleural diseases (e.g., serositis, shrinking lung syndrome), and vascular diseases (e.g., pulmonary arterial hypertension, pulmonary embolism, acute reversible hypoxemia syndrome). We discuss diagnostic modalities, treatment strategies, and prognosis for each pulmonary manifestation. With diagnostics remaining a challenge and with the absence of standardized treatment guidelines, we emphasize the need for evidence-based guidelines to optimize patient care and improve outcomes in this complex disease.
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Affiliation(s)
- Elisabeth Bendstrup
- Center for Rare Lung Disease, Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Evelyn Lynn
- Department of Respiratory Medicine, St. Vincent's University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Anne Troldborg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Biomedicine, Aarhus University, Aarhus, Denmark
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Nagashima T, Yabe H, Ogishi T, Kobashigawa T. Diffuse Alveolar Hemorrhage Caused by Disseminated Cryptococcosis in a Patient With Systemic Lupus Erythematosus. Cureus 2024; 16:e53831. [PMID: 38465028 PMCID: PMC10924431 DOI: 10.7759/cureus.53831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 03/12/2024] Open
Abstract
A teenage girl with systemic lupus erythematosus (SLE) was admitted with fever, dry cough, and dyspnea on exertion. Chest computed tomography revealed bilateral diffuse infiltration and swelling of the mediastinal lymph nodes. The bronchoalveolar lavage (BAL) fluid was light red, suggesting diffuse alveolar hemorrhage (DAH). Therefore, glucocorticoid pulse therapy was initiated. However, blood and BAL fluid cultures showed the growth of Cryptococcus neoformans. The patient was diagnosed with disseminated cryptococcosis. The patient was treated with liposomal amphotericin B and flucytosine; the prednisolone dose was rapidly tapered. Infections should be thoroughly ruled out in patients with SLE and DAH.
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Affiliation(s)
- Takao Nagashima
- Division of Rheumatology, First Department of Comprehensive Medicine, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Hiroki Yabe
- Division of Rheumatology, First Department of Comprehensive Medicine, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Toshiaki Ogishi
- Division of Rheumatology, First Department of Comprehensive Medicine, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Tsuyoshi Kobashigawa
- Division of Rheumatology, First Department of Comprehensive Medicine, Saitama Medical Center, Jichi Medical University, Saitama, JPN
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Xu L, Yang R, Cao Y, Wang M, Yang X. Risk factors of diffuse alveolar hemorrhage in Chinese patients with systemic lupus erythematosus. Sci Rep 2023; 13:22381. [PMID: 38104153 PMCID: PMC10725482 DOI: 10.1038/s41598-023-49978-2] [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: 06/28/2023] [Accepted: 12/14/2023] [Indexed: 12/19/2023] Open
Abstract
This study aimed to investigate the frequency and features of diffuse alveolar hemorrhage (DAH) in Chinese patients with systemic lupus erythematosus (SLE) and evaluate the association of DAH with the features. A total of 943 patients with SLE were categorized into two groups: 896 patients without DAH and 47 patients with DAH. The demographic data, clinical and laboratory findings, and SLE disease activity index 2000 of all patients were statistically analyzed. The DAH frequency in patients with SLE was 4.98%, and the mortality rate of DAH was 42.55%. The clinical features with statistical differences between the two groups were analyzed by multivariate logistic regression, and the results suggested that shorter disease duration [odds ratio (OR): 0.972, 95% confidence interval (CI) 0.946, 0.998], younger age (OR: 0.867, 95% CI 0.764, 0.984), moderate (OR: 25.949, 95% CI 3.316, 203.065) or severe (OR: 24.904, 95% CI 2.675, 231.859) anemia, abnormally elevated levels of urine protein (OR: 10.839, 95% CI 1.351, 86.938) and serum creatinine (OR: 14.534, 95% CI 5.012, 42.142), interstitial lung disease (OR: 6.569, 95% CI 2.053, 21.021), and infection (OR: 8.890, 95% CI 3.580, 22.077) were independent risk factors for the occurrence of DAH in patients with SLE. Moderate or severe anemia was highly suggestive of DAH.
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Affiliation(s)
- Lishan Xu
- Department of Rheumatology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Rong Yang
- Follow-Up Center, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yingping Cao
- Department of Laboratory Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Meihua Wang
- Department of Laboratory Medicine, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Xuwei Yang
- Department of Rheumatology, Fujian Medical University Union Hospital, Fuzhou, China.
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Law AH, Chuah TY, Lee W, Teng GG, Lian TY, Saffari SE, Chew LC. Diffuse alveolar haemorrhage in systemic lupus erythematosus: A multicentre retrospective study in Singapore. Lupus 2023:9612033231180704. [PMID: 37268601 DOI: 10.1177/09612033231180704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Diffuse alveolar haemorrhage (DAH) is a rare but life-threatening complication of systemic lupus erythematosus (SLE). We describe the clinical characteristics, treatment and survival outcomes of SLE patients with DAH in Singapore. METHODS We conducted a retrospective review of the medical records of SLE patients with DAH hospitalised in 3 tertiary hospitals between January 2007 and October 2017. Patient demographics, clinical characteristics, laboratory, radiologic and bronchoscopic findings, as well as the treatments, were compared between survivors and non-survivors. Survival rates were analysed between the various treatment groups. RESULTS A total of 35 patients with DAH were included in this study. Majority of them were female (71.4%) and of Chinese ethnicity (62.9%). Median age was 40.0 years (IQR: 25-54), with a median disease duration of 8.9 months (IQR: 0.13-102.4). Haemoptysis was the most common clinical presentation, and majority had concomitant cytopaenia and lupus nephritis. All patients received high dose glucocorticoids; 27 (77.1%), 16 (45.7%) and 23 (65.7%) received cyclophosphamide (CYP), rituximab (RTX), and plasmapheresis (PLEX), respectively. Twenty-two patients required mechanical ventilation with a median duration of 12 days. Overall mortality rate was 40%, with a median survival time of 162 days. Twenty-six patients (74.3%) achieved remission, with an overall median time to remission of 12 days (IQR: 6-46) after diagnosis of DAH. Patients on triple therapy (CYP, RTX and PLEX) had a median survival of 162 days as compared to 14 days in patients on PLEX alone (p = .0026). CONCLUSIONS The overall mortality of DAH in SLE patients remained high. There were no significant differences in patient demographics or clinical characteristics between the survivors and non-survivors. However, better survival appears to be associated with treatment with cyclophosphamide.
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Affiliation(s)
- Annie Hn Law
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tyng Yu Chuah
- Department of General Medicine (Rheumatology), Sengkang General Hospital, Singapore
| | - Weixian Lee
- Department of Medicine (Rheumatology), Ng Teng Fong General Hospital, Singapore
| | - Gim Gee Teng
- Department of Rheumatology, National University Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tsui Yee Lian
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Seyed Ehsan Saffari
- Centre for Quantitative Medicine, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Li-Ching Chew
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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He X, Jiang L, Hu L, Du P, Zhu M, Wu H, Zhao M, Lu Q. Mivebresib alleviates systemic lupus erythematosus-associated diffuse alveolar hemorrhage via inhibiting infiltration of monocytes and M1 polarization of macrophages. Int Immunopharmacol 2023; 120:110305. [PMID: 37182455 DOI: 10.1016/j.intimp.2023.110305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/23/2023] [Accepted: 05/05/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is a serious complication that can arise from systemic lupus erythematosus (SLE) and other autoimmune diseases. While current treatments for DAH have limitations and adverse side effects, recent evidence suggests that inflammatory macrophages play a crucial role in the development of DAH. In this study, we investigated Mivebresib, a BET protein-bromodomain-containing protein 4 (BRD4) inhibitor, as a potential treatment for DAH. RESULTS Our findings show that Mivebresib effectively protected C57BL/6J mice against pristane-induced DAH by inhibiting the migration and polarization of monocytes and macrophages, as well as pathogenic B and T cells. Specifically, Mivebresib modified the distribution of leukocytes, impeded the polarization of inflammatory macrophages, and reduced the frequency of CD19 + CD5 + B cells in the lungs of pristane-treated mice. Furthermore, in vitro experiments demonstrated that Mivebresib inhibited LPS-induced M1 polarization of macrophages and the expression of pro-inflammatory cytokines, M1 marker genes, and chemokines-chemokine receptors while thwarting the secretion of IL-6 and TNF-α. Transcriptomic analysis suggested and experiments comfimed that Mivebresib inhibits M1 polarization via interrupting the p300/BRD4/HIF1A axis. CONCLUSIONS Our study demonstrates that Mivebresib has therapeutic potential for the life-threatening complication of DAH caused by SLE. By inhibiting macrophage polarization and the infiltration of inflammatory cells, Mivebresib may offer a promising treatment option for patients suffering from this disease.
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Affiliation(s)
- Xieling He
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Li Jiang
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Longyuan Hu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Pei Du
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ming Zhu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Haijing Wu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ming Zhao
- Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences, Nanjing, China; Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China; Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China; Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital, Central South University, Changsha, China.
| | - Qianjin Lu
- Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences, Nanjing, China; Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China; Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China; Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital, Central South University, Changsha, China.
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Li M, Bai W, Wang Y, Song L, Zhang S, Zhao J, Wu C, Li M, Tian X, Zeng X. Infection in systemic lupus erythematosus-associated diffuse alveolar hemorrhage: a potential key to improve outcomes. Clin Rheumatol 2023; 42:1573-1584. [PMID: 36797549 DOI: 10.1007/s10067-023-06517-8] [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: 08/29/2022] [Revised: 12/21/2022] [Accepted: 01/17/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVES This study aimed to investigate the clinical characteristics, outcomes, and associated factors of patients with systemic lupus erythematosus-associated diffusive alveolar hemorrhage (SLE-DAH) stratified by infection status in a national representative cohort. METHODS This single-center retrospective study included 124 consecutive patients with SLE-DAH in a tertiary care center between 2006 and 2021. The diagnosis of DAH was made based on a comprehensive evaluation of clinical manifestations, laboratory and radiologic findings, and bronchoalveolar lavage. Demographics, clinical features, and survival curves were compared between patients with bacterial, non-bacterial, and non-infection groups. Univariate and multivariate logistic regression analyses were performed to determine the factors independently associated with bacterial infection in SLE-DAH. RESULTS Fifty-eight patients with SLE-DAH developed bacterial infection after DAH occurrence, thirty-two patients developed fungal and/or viral infection, and thirty-four patients were categorized as non-infection. The bacterial infection group have a worse prognosis (OR 3.059, 95%CI 1.469-6.369, p = 0.002) compared with the other two groups, with a mortality rate of 60.3% within 180 days after DAH occurrence. Factors independently associated with bacterial infections in SLE-DAH included hematuria (OR 4.523, 95%CI 1.068-19.155, p = 0.040), hemoglobin drop in the first 24 h after DAH occurred (OR 1.056, 95%CI 1.001-1.115, p = 0.049), and anti-Smith antibody (OR 0.167, 95%CI 0.052-0.535, p = 0.003). Glucocorticoid pulse therapy and cyclophosphamide were administered in more than 50% of patients regardless of their infectious status. According to clinical experience at our hospital and in previous studies, we recommended a comprehensive management algorithm for SLE-DAH based on infection stratification. CONCLUSION Infection, especially bacterial infection, is a severe complication and prognostic factor of SLE-DAH. Comprehensive management strategies, including diagnosis, evaluation, treatment, and monitoring, based on infection stratification may fundamentally improve outcomes of patients with SLE-DAH. Key Points • Bacterial infection is an important, but neglected, prognosis factor of systemic lupus erythematosus (SLE)-associated diffusive alveolar hemorrhage (DAH). • Hematuria, hemoglobin drop, and anti-Smith antibody can independently predict bacterial infections in SLE-DAH. • We put forward a comprehensive management algorithm based on infection stratification for SLE-DAH.
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Affiliation(s)
- Mucong Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Wei Bai
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Yanhong Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking, Union Medical College, Beijing, 100730, China
| | - Lan Song
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Shangzhu Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Chanyuan Wu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
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A Case of Previously Undiagnosed Systemic Lupus Erythematosus and Mycobacterium tuberculosis Infection Presenting as Diffuse Alveolar Hemorrhage. Case Rep Rheumatol 2023; 2023:3686772. [PMID: 36686202 PMCID: PMC9848806 DOI: 10.1155/2023/3686772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 01/13/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is described as the collection of blood in alveolar spaces caused by damaged pulmonary vasculature. It often presents as a life-threatening medical emergency that requires urgent medical intervention along with timely diagnosis and management of the underlying cause. We hereby report a 19-year-old female who presented with clinical and radiological characteristics consistent with DAH. Laboratory workup studies revealed a diagnosis of systemic lupus erythematosus (SLE) as well as Mycobacterium tuberculosis (MTB) infection. This report describes an extremely unusual case of undiagnosed SLE and coexistent tuberculosis presenting as DAH. This leads to an interesting possibility of risks in patients with immune-mediated vasculitis towards developing severe pulmonary disease in the setting of pulmonary mycobacterial infection.
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9
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Zhuang H, Hudson E, Han S, Arja RD, Hui W, Lu L, Reeves WH. Microvascular lung injury and endoplasmic reticulum stress in systemic lupus erythematosus-associated alveolar hemorrhage and pulmonary vasculitis. Am J Physiol Lung Cell Mol Physiol 2022; 323:L715-L729. [PMID: 36255715 PMCID: PMC9744657 DOI: 10.1152/ajplung.00051.2022] [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: 02/11/2022] [Revised: 10/13/2022] [Accepted: 10/13/2022] [Indexed: 12/14/2022] Open
Abstract
Human COPA mutations affecting retrograde Golgi-to-endoplasmic reticulum (ER) protein transport cause diffuse alveolar hemorrhage (DAH) and ER stress ("COPA syndrome"). Patients with SLE also can develop DAH. C57BL/6 (B6) mice with pristane-induced lupus develop monocyte-dependent DAH indistinguishable from human DAH, whereas BALB/c mice are resistant. We examined Copa and ER stress in pristane-induced lupus. Copa expression, ER stress, vascular injury, and apoptosis were assessed in mice and COPA was quantified in blood from patients with SLE. Copa mRNA and protein expression were impaired in B6 mice with pristane-induced DAH, but not in pristane-treated BALB/c mice. An ER stress response (increased Hsp5a/BiP, Ddit3/CHOP, Eif2a, and spliced Xbp1) was seen in lungs from pristane-treated B6, but not BALB/c, mice. Resistance of BALB/c mice to DAH was overcome by treating them with low-dose thapsigargin plus pristane. CB6F1 mice did not develop DAH or ER stress, suggesting that susceptibility was recessive. Increased pulmonary expression of von Willebrand factor (Vwf), a marker of endothelial injury, and the chemokine Ccl2 in DAH suggested that pristane promotes lung microvascular injury and monocyte recruitment. Consistent with that possibility, lung endothelial cells and infiltrating bone marrow-derived cells from pristane-treated B6 mice expressed BiP and showed evidence of apoptosis (annexin-V and activated caspase-3 staining). COPA expression also was low in patients with SLE with lung involvement. Pristane-induced DAH may be initiated by endothelial injury, resulting in ER stress, apoptosis of lung endothelial cells, and recruitment of myeloid cells that propagate lung injury. The pathogenesis of DAH in SLE and COPA syndrome may overlap.
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Affiliation(s)
- Haoyang Zhuang
- Division of Rheumatology, Allergy, & Clinical Immunology, University of Florida, Gainesville, Florida
| | - Erin Hudson
- Division of Rheumatology, Allergy, & Clinical Immunology, University of Florida, Gainesville, Florida
| | - Shuhong Han
- Division of Rheumatology, Allergy, & Clinical Immunology, University of Florida, Gainesville, Florida
| | - Rawad Daniel Arja
- Division of Rheumatology, Allergy, & Clinical Immunology, University of Florida, Gainesville, Florida
| | - Winnie Hui
- Division of Rheumatology, Allergy, & Clinical Immunology, University of Florida, Gainesville, Florida
| | - Li Lu
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Westley H Reeves
- Division of Rheumatology, Allergy, & Clinical Immunology, University of Florida, Gainesville, Florida
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, Florida
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10
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Reibaldi AA, Sager L, Calvo R, Ortiz A, Roverano S, Paira S, Fernández de Carrera E. Diffuse alveolar haemorrhage in systemic lupus erythematosus patients. REUMATOLOGIA CLINICA 2022; 18:84-90. [PMID: 35153041 DOI: 10.1016/j.reumae.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 09/03/2020] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Pulmonary haemorrhage (PH) in systemic lupus erythematosus (SLE) is a rare but potentially fatal complication due to its high mortality. Early treatment benefits the outcome. Reports on predictive factors of PH in SLE patients are scarce. OBJECTIVE To describe a case series of PH in SLE patients that were attended in the Rheumatology Section of the J. M. Cullen Hospital and to compare this data with published results. METHODS Patients with SLE (1982-1997 ACR criteria) and PH diagnosed by clinical criteria (cough, dyspnoea, haemoptysis), haemoglobin below 12 g/dL or drop greater than 2 points, new radiological infiltrate and bronchioalveolar lavage, monitored between June 1987 and December 2019 were studied. Demographic, clinical, laboratory, treatment and prognosis data related to PH were analysed. RESULTS From a database of 306 SLE patients, 25 (8.2%) developed 29 episodes of PH. PH was the first manifestation of SLE in 8 patients. Renal involvement was the most frequent manifestation prior to the development of PH. SLE activity (measured by SLEDAI) was high during the episodes (mean: 16.8). Renal failure (p = .027) and mechanical respiratory support (p = .006) were related to mortality (40.7%) with statistical significance. Patients with SLEDAI higher to 10 at SLE onset showed more likelihood of developing PH. The OR was 2.68 (p = .046). CONCLUSIONS Although treatment in SLE has progressed in recent years, PH continues to be a rare and severe complication of this disease. When a PH is suspected, studies to confirm it must be done rapidly, since early diagnosis and aggressive treatment have been shown to improve survival. We observed that patients with renal involvement and mechanical respiratory support had higher mortality than SLE patients without them.
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Affiliation(s)
| | - Lorena Sager
- Sección Reumatología, Hospital José María Cullen, Santa Fe, Argentina
| | - Romina Calvo
- Sección Reumatología, Hospital José María Cullen, Santa Fe, Argentina
| | - Alberto Ortiz
- Sección Reumatología, Hospital José María Cullen, Santa Fe, Argentina
| | - Susana Roverano
- Sección Reumatología, Hospital José María Cullen, Santa Fe, Argentina
| | - Sergio Paira
- Sección Reumatología, Hospital José María Cullen, Santa Fe, Argentina
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Rajasekhar L, Devarasetti P, Appani S, Prasad Irlapati R. Predictors of mortality in diffuse alveolar hemorrhage in systemic lupus erythematosus. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_82_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Chen YC, Chou YC, Hsieh YT, Kuo PY, Yang ML, Chong HE, Wu CL, Shiau AL, Wang CR. Targeting Intra-Pulmonary P53-Dependent Long Non-Coding RNA Expression as a Therapeutic Intervention for Systemic Lupus Erythematosus-Associated Diffuse Alveolar Hemorrhage. Int J Mol Sci 2021; 22:ijms22136948. [PMID: 34203338 PMCID: PMC8268786 DOI: 10.3390/ijms22136948] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/17/2021] [Accepted: 06/23/2021] [Indexed: 12/13/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) in systemic lupus erythematosus (SLE) is associated with significant mortality, requiring a thorough understanding of its complex mechanisms to develop novel therapeutics for disease control. Activated p53-dependent apoptosis with dysregulated long non-coding RNA (lncRNA) expression is involved in the SLE pathogenesis and correlated with clinical activity. We examined the expression of apoptosis-related p53-dependent lncRNA, including H19, HOTAIR and lincRNA-p21 in SLE-associated DAH patients. Increased lincRNA-p21 levels were detected in circulating mononuclear cells, mainly in CD4+ and CD14+ cells. Higher expression of p53, lincRNA-p21 and cell apoptosis was identified in lung tissues. Lentivirus-based short hairpin RNA (shRNA)-transduced stable transfectants were created for examining the targeting efficacy in lncRNA. Under pristane stimulation, alveolar epithelial cells had increased p53, lincRNA-p21 and downstream Bax levels with elevated apoptotic ratios. After pristane injection, C57/BL6 mice developed DAH with increased pulmonary expression of p53, lincRNA-p21 and cell apoptosis. Intra-pulmonary delivery of shRNA targeting lincRNA-p21 reduced hemorrhage frequencies and improved anemia status through decreasing Bax expression and cell apoptosis. Our findings demonstrate increased p53-dependent lncRNA expression with accelerated cell apoptosis in the lungs of SLE-associated DAH patients, and show the therapeutic potential of targeting intra-pulmonary lncRNA expression in a pristane-induced model of DAH.
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Affiliation(s)
- Yi-Cheng Chen
- Department of Internal Medicine, Medical College and Hospital, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-C.C.); (H.-E.C.)
- Department of Medical Research, Ditmanson Medical Foundation, Chiayi Christian Hospital, Chiayi 600566, Taiwan
- Department of Biochemistry and Molecular Biology, National Cheng Kung University Medical College, Tainan 70403, Taiwan;
| | - Yu-Chi Chou
- Biomedical Translation Research Center, Academia Sinica, Taipei 11529, Taiwan;
| | - Yu-Tung Hsieh
- Department of Microbiology and Immunology, Medical College, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-T.H.); (P.-Y.K.); (M.-L.Y.); (A.-L.S.)
| | - Pin-Yu Kuo
- Department of Microbiology and Immunology, Medical College, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-T.H.); (P.-Y.K.); (M.-L.Y.); (A.-L.S.)
| | - Mei-Lin Yang
- Department of Microbiology and Immunology, Medical College, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-T.H.); (P.-Y.K.); (M.-L.Y.); (A.-L.S.)
| | - Hao-Earn Chong
- Department of Internal Medicine, Medical College and Hospital, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-C.C.); (H.-E.C.)
| | - Chao-Liang Wu
- Department of Biochemistry and Molecular Biology, National Cheng Kung University Medical College, Tainan 70403, Taiwan;
| | - Ai-Li Shiau
- Department of Microbiology and Immunology, Medical College, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-T.H.); (P.-Y.K.); (M.-L.Y.); (A.-L.S.)
| | - Chrong-Reen Wang
- Department of Internal Medicine, Medical College and Hospital, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-C.C.); (H.-E.C.)
- Department of Microbiology and Immunology, Medical College, National Cheng Kung University, Tainan 70403, Taiwan; (Y.-T.H.); (P.-Y.K.); (M.-L.Y.); (A.-L.S.)
- Correspondence: ; Tel.: +886-6-235-3535 (ext. 5366)
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Risk factors for mortality of diffuse alveolar hemorrhage in systemic lupus erythematosus: a systematic review and meta-analysis. Arthritis Res Ther 2021; 23:57. [PMID: 33593433 PMCID: PMC7885396 DOI: 10.1186/s13075-021-02435-9] [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] [Received: 07/21/2020] [Accepted: 02/01/2021] [Indexed: 12/15/2022] Open
Abstract
Background Diffuse alveolar hemorrhage (DAH) is a rare but life-threatening complication of systemic lupus erythematosus (SLE). The current knowledge of the prognostic factors for SLE-associated DAH is controversial. This meta-analysis was undertaken to investigate the relevant risk factors for mortality in SLE-associated DAH. Methods Studies were searched from PubMed, EMBASE, and Web of Science databases published up to May 27, 2020, and were selected or removed according to the inclusion and exclusion criteria. Two reviewers extracted data independently from the enrolled studies, and the odds ratios (OR) or the standardized mean difference (SMD) was utilized to identify and describe the prognostic factors for mortality. Results Eight studies encompassing 251 patients with SLE-associated DAH were included in the meta-analysis. No significant publication bias was shown. Age at the diagnosis of DAH (SMD = 0.35, 95% confidence interval (CI) (0.08, 0.61), P = 0.01, I2 = 0.0%) was found to be an independent risk factor of mortality. Longer lupus disease duration (SMD = 0.28, 95% CI (0.01, 0.55), P = 0.042, I2 = 0.0%), concurrent infection (OR = 2.77, 95% CI (1.55, 4.95), P = 0.001, I2 = 37.5%), plasmapheresis treatment (OR = 1.96, 95% CI (1.04, 3.70), P = 0.038, I2 = 14.6%), and mechanical ventilation (OR = 6.11, 95% CI (3.27, 11.39), P < 0.0001, I2 = 23.3%) were also related to poor survival, whereas no noticeable relationships were revealed between survival and concurrent lupus nephritis (OR = 5.45, 95% CI (0.52, 56.95), P = 0.16, I2 = 58.4%) or treatment of cyclophosphamide (CTX) (OR = 0.74, 95% CI (0.16, 3.41), P = 0.70, I2 = 75.5%). Conclusions Older age at the diagnosis of DAH, longer disease duration of SLE, concurrent infection, plasmapheresis treatment, and mechanical ventilation were found related to increased mortality in patients with SLE-associated DAH according to our meta-analysis. However, due to limited studies with heterogeneity, these results should be interpreted cautiously. Notably, severe diseases rendered the requirement of plasmapheresis treatment and mechanical ventilation are themselves associated with poor outcome. Randomized trials of therapeutics are needed to determine the most efficacious strategies for SLE-associated DAH for better management of this life-threatening complication. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-021-02435-9.
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Battaglia M, Garrett-Sinha LA. Bacterial infections in lupus: Roles in promoting immune activation and in pathogenesis of the disease. J Transl Autoimmun 2020; 4:100078. [PMID: 33490939 PMCID: PMC7804979 DOI: 10.1016/j.jtauto.2020.100078] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/11/2020] [Accepted: 12/16/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Bacterial infections of the lung, skin, bloodstream and other tissues are common in patients with systemic lupus erythematosus (lupus) and are often more severe and invasive than similar infections in control populations. A variety of studies have explored the changes in bacterial abundance in lupus patients, the rates of infection and the influence of particular bacterial species on disease progression, using both human patient samples and mouse models of lupus. OBJECTIVE The aim of this review is to summarize human and mouse studies that describe changes in the bacterial microbiome in lupus, the role of a leaky gut in stimulating inflammation, identification of specific bacterial species associated with lupus, and the potential roles of certain common bacterial infections in promoting lupus progression. METHODS Information was collected using searches of the Pubmed database for articles relevant to bacterial infections in lupus and to microbiome changes associated with lupus. RESULTS The reviewed studies demonstrate significant changes in the bacterial microbiome of lupus patients as compared to control subjects and in lupus-prone mice compared to control mice. Furthermore, there is evidence supporting the existence of a leaky gut in lupus patients and in lupus-prone mice. This leaky gut may allow live bacteria or bacterial components to enter the circulation and cause inflammation. Invasive bacterial infections are more common and often more severe in lupus patients. These include infections caused by Staphylococcus aureus, Salmonella enterica, Escherichia coli, Streptococcus pneumoniae and mycobacteria. These bacterial infections can trigger increased immune activation and inflammation, potentially stimulating activation of autoreactive lymphocytes and leading to worsening of lupus symptoms. CONCLUSIONS Together, the evidence suggests that lupus predisposes to infection, while infection may trigger worsening lupus, leading to a feedback loop that may reinforce autoimmune symptoms.
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Affiliation(s)
- Michael Battaglia
- Department of Biochemistry, State University of New York at Buffalo, Buffalo, NY, 14203, USA
| | - Lee Ann Garrett-Sinha
- Department of Biochemistry, State University of New York at Buffalo, Buffalo, NY, 14203, USA
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Reibaldi AA, Sager L, Calvo R, Ortiz A, Roverano S, Paira S, Fernández de Carrera E. Diffuse Alveolar Haemorrhage in Systemic Lupus Erythematosus Patients. REUMATOLOGIA CLINICA 2020; 18:S1699-258X(20)30226-6. [PMID: 33246912 DOI: 10.1016/j.reuma.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 08/26/2020] [Accepted: 09/03/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Pulmonary haemorrhage (PH) in systemic lupus erythematosus (SLE) is a rare but potentially fatal complication due to its high mortality. Early treatment benefits the outcome. Reports on predictive factors of PH in SLE patients are scarce. OBJECTIVE To describe a case series of PH in SLE patients that were attended in the Rheumatology Section of the J. M. Cullen Hospital and to compare this data with published results. METHODS Patients with SLE (1982-1997 ACR criteria) and PH diagnosed by clinical criteria (cough, dyspnoea, haemoptysis), haemoglobin below 12 g/dL or drop greater than 2 points, new radiological infiltrate and bronchioalveolar lavage, monitored between June 1987 and December 2019 were studied. Demographic, clinical, laboratory, treatment and prognosis data related to PH were analysed. RESULTS From a database of 306 SLE patients, 25 (8.2%) developed 29 episodes of PH. PH was the first manifestation of SLE in 8 patients. Renal involvement was the most frequent manifestation prior to the development of PH. SLE activity (measured by SLEDAI) was high during the episodes (mean: 16.8). Renal failure (p = 0.027) and mechanical respiratory support (p = 0.006) were related to mortality (40.7%) with statistical significance. Patients with SLEDAI higher to 10 at SLE onset showed more likelihood of developing PH. The OR was 2.68 (p = 0.046). CONCLUSIONS Although treatment in SLE has progressed in recent years, PH continues to be a rare and severe complication of this disease. When a PH is suspected, studies to confirm it must be done rapidly, since early diagnosis and aggressive treatment have been shown to improve survival. We observed that patients with renal involvement and mechanical respiratory support had higher mortality than SLE patients without them.
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Affiliation(s)
| | - Lorena Sager
- Sección Reumatología, Hospital José María Cullen, Santa Fe, Argentina
| | - Romina Calvo
- Sección Reumatología, Hospital José María Cullen, Santa Fe, Argentina
| | - Alberto Ortiz
- Sección Reumatología, Hospital José María Cullen, Santa Fe, Argentina
| | - Susana Roverano
- Sección Reumatología, Hospital José María Cullen, Santa Fe, Argentina
| | - Sergio Paira
- Sección Reumatología, Hospital José María Cullen, Santa Fe, Argentina
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Lai CC, Sun YS, Lin FC, Yang CY, Tsai CY. Bronchoalveolar lavage fluid analysis and mortality risk in systemic lupus erythematosus patients with pneumonia and respiratory failure. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2020; 54:1048-1055. [PMID: 32675043 DOI: 10.1016/j.jmii.2020.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/23/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Our aim was to characterize etiologic diagnoses obtained from bronchoalveolar lavage fluid (BALF) and blood specimens, and to identify risk factors for mortality in systemic lupus erythematosus (SLE) patients with pneumonia and respiratory failure. METHODS We conducted a retrospective analysis of SLE patients with pneumonia and respiratory failure. Clinical characteristics, laboratory profiles, and microbiology in BALF and blood samples were evaluated. We performed univariable analyses to identify mortality risk factors. RESULTS All 24 patients (F:M = 21:3, median age 46.5 years; disease duration 11 years) received mechanical ventilation (median duration: 11 days). Pathogens identified in BALF included Pneumocystis jiroveci (12 patients [50%]), cytomegalovirus (CMV, 7 patients [29.2%]), and bacteria (11 patients [45.8%]). Thirteen patients (54.2%) yielded pathogens in blood (CMV in 8 patients [33.3%] and Escherichia coli in 5 patients [20.8%]). Eight developed septic shock, and 9 died within 30 days. Univariable analysis identified thrombocytopenia (odds ratio [OR]: 8.0, 95% confidence interval [CI]: 1.23-52.25), bacteremia within 30 days before or after endotracheal intubation (OR: 8.0, 95% CI: 1.23-52.5), and P. jiroveci pneumonia (PJP, OR: 7.0, 95% CI: 1.04-46.95) as risk factors for 30-day mortality. Kaplan-Meier analysis confirmed an increased risk of 30-day mortality with thrombocytopenia and bacteremia. CONCLUSION There are high prevalence rates of PJP and CMV infections as evidenced by BALF analyses in SLE patients with pneumonia and respiratory failure. BALF analysis can facilitate rescue therapy per pathogen. Thrombocytopenia, bacteremia, and PJP in SLE patients can increase their 30-day mortality, so warrant early and aggressive treatments.
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Affiliation(s)
- Chien-Chih Lai
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taiwan; Faculty of Medicine, National Yang-Ming University, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taiwan
| | - Yi-Syuan Sun
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taiwan; Faculty of Medicine, National Yang-Ming University, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taiwan
| | - Fang-Chi Lin
- Department of Chest Medicine, Taipei Veterans General Hospital, Taiwan
| | - Chih-Yu Yang
- Institute of Clinical Medicine, National Yang-Ming University, Taiwan; Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taiwan; Center for Intelligent Drug Systems and Smart Bio-devices (IDS(2)B), Taiwan
| | - Chang-Youh Tsai
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taiwan; Faculty of Medicine, National Yang-Ming University, Taiwan.
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Sun Y, Zhou C, Zhao J, Wang Q, Xu D, Zhang S, Shen M, Hou Y, Tian X, Li M, Zeng X. Systemic lupus erythematosus-associated diffuse alveolar hemorrhage: a single-center, matched case-control study in China. Lupus 2020; 29:795-803. [PMID: 32321345 DOI: 10.1177/0961203320920715] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND This study described clinical characteristics and outcome in systemic lupus erythematosus (SLE) patients with diffuse alveolar hemorrhage (DAH), and investigated risk factors and prognostic factors for DAH. METHODS We conducted a retrospective nested case-control analysis in a single-center cohort. We enrolled 94 SLE patients with DAH. For each case of DAH, two age-, sex-, and SLE courses-matched controls were randomly selected from our cohort. All patients were enrolled between 2004 and 2019 and were followed until death, end of registration with the physician's practice, or end of January 2019. We estimated the risk factors for DAH and prognostic factors for mortality using multivariate analysis. RESULTS We included 4744 patients diagnosed with SLE, with 94 cases of DAH, for an incidence rate of 2.0%. DAH may occur in any stage of SLE but mostly in the early phase of disease course. Lupus nephritis (LN) was the most common concomitant involvement at DAH diagnosis. By multivariate analysis, LN, anti-SSA positivity, thrombocytopenia and elevated C-reactive protein (CRP) were significantly associated with DAH in SLE patients. All-cause mortality was increased in SLE with DAH compared with SLE without DAH (adjusted hazard ratio 6.0, 95% confidence interval 2.8-13.0, p < 0.0001). Intravenous cyclophosphamide (CTX) showed an increased tendency for better survival in DAH after adjusting for Systemic Lupus Erythematosus Disease Activity Index 2000, acute kidney injury and mechanical ventilation. CONCLUSIONS LN, anti-SSA positivity, thrombocytopenia and elevated CRP were independent risk factors of DAH in lupus patients. Due to a high early death rate of DAH and little long-term damage, DAH patients may benefit from early diagnosis and intensive treatment, and CTX-based therapy can be a preferential choice.
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Affiliation(s)
- Yiduo Sun
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Cong Zhou
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Dong Xu
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Min Shen
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Yong Hou
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China
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Severe Infection in Anti-Glomerular Basement Membrane Disease: A Retrospective Multicenter French Study. J Clin Med 2020; 9:jcm9030698. [PMID: 32143501 PMCID: PMC7141378 DOI: 10.3390/jcm9030698] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 12/23/2022] Open
Abstract
In patients presenting with anti-glomerular basement membrane (GBM) disease with advanced isolated kidney involvement, the benefit of intensive therapy remains controversial due to adverse events, particularly infection. We aim to describe the burden of severe infections (SI) (requiring hospitalization or intravenous antibiotics) and identify predictive factors of SI in a large cohort of patients with anti-GBM disease. Among the 201 patients (median [IQR] age, 53 [30–71] years) included, 74 had pulmonary involvement and 127 isolated glomerulonephritis. A total of 161 SI occurred in 116 patients during the first year after diagnosis. These infections occurred during the early stage of care (median [IQR] time, 13 [8–19] days after diagnosis) with mainly pulmonary (45%), catheter-associated bacteremia (22%) and urinary tract (21%) infections. In multivariable analysis, positive ANCA (HR [95% CI] 1.62 [1.07−2.44]; p = 0.02) and age at diagnosis (HR [95% CI] 1.10 [1.00–1.21]; p = 0.047) remained independently associated with SI. Age-adjusted severe infection during the first three months was associated with an increased three-year mortality rate (HR [95% CI] 3.13 [1.24–7.88]; p = 0.01). Thus, SI is a common early complication in anti-GBM disease, particularly in the elderly and those with positive anti-neutrophil cytoplasmic antibodies (ANCA). No significant association was observed between immunosuppressive strategy and occurrence of SI.
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Al-Adhoubi NK, Bystrom J. Systemic lupus erythematosus and diffuse alveolar hemorrhage, etiology and novel treatment strategies. Lupus 2020; 29:355-363. [PMID: 32036761 PMCID: PMC7436451 DOI: 10.1177/0961203320903798] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Diffuse alveolar hemorrhage is a severe respiratory complication of systemic lupus erythematosus. The illness develops over hours to a few days and is the systemic lupus erythematosus-associated syndrome with highest mortality. Although no specific symptoms have been identified, a number of features are associated with diffuse alveolar hemorrhage, with a drop in blood hemoglobin the most prominent. Dyspnea, blood-stained sputum, diffuse infiltrates identified by chest imaging, elevated single breath-diffusing capacity for monoxide, thrombocytopenia and C3 hypocomplementemia are other commonly reported signs of diffuse alveolar hemorrhage. The etiology is not completely understood but many patients develop diffuse alveolar hemorrhage concomitant with lupus nephritis, suggesting immune complex-driven pathology. Biopsy studies have identified both cases with capillaritis and a bland non-inflammatory phenotype. An animal model of diffuse alveolar hemorrhage has indicated requirement of B lymphocytes and complement receptor-mediated apoptotic body phagocytosis by monocytes as part of the pathogenesis. This review will discuss considerations when diagnosing the condition and available therapies. Infections and other causes of hemorrhage have to be excluded as these require different treatment strategies. Methylprednisolone and cyclophosphamide remain the most commonly used therapies. Plasmapheresis and rituximab are other beneficial treatment options. A few studies have also considered intrapulmonary Factor VII therapy, extracorporeal membrane oxygenation and mesenchymal stem cell therapy. There is an unmet need of better definition of diffuse alveolar hemorrhages etiology and pathology for development of improved treatment strategies.
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Affiliation(s)
- N K Al-Adhoubi
- Department of Rheumatology, Royal Hospital, Muscat, Oman
| | - J Bystrom
- Centre for Experimental Medicine and Rheumatology, Queen Mary University of London, London, United Kingdom
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Pulmonary manifestations in systemic lupus erythematosus: pleural involvement, acute pneumonitis, chronic interstitial lung disease and diffuse alveolar hemorrhage. ACTA ACUST UNITED AC 2019; 14:294-300. [PMID: 29773465 DOI: 10.1016/j.reuma.2018.03.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/28/2018] [Accepted: 03/22/2018] [Indexed: 12/29/2022]
Abstract
Systemic lupus erythematosus is the diffuse autoimmune connective tissue disease that most frequently involves pulmonary involvement, affecting 20% of 90% of the patients. The percentage varies depending on the defining criteria (symptoms, pulmonary tests or histopathological studies). At least once during the disease course, 50% of those affected have pleural and/or pulmonary manifestations, which are associated with higher morbidity and mortality. Pulmonary involvement has no correlation with lupus activity biomarkers, and it is necessary to rule out infectious processes in the initial approach. Bacterial infection is most frequently the cause of lung involvement in lupus and is one of the most important causes of death. Pulmonary involvement is considered to be primary when it is associated with disease activity, and secondary when other causes participate. Drugs have been reported to be associated with pulmonary damage, including interstitial disease. The incidence of malignant lung diseases is increased in systemic lupus erythematosus. Treatment depends on the type and severity of pulmonary involvement.
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Sun YS, Huang DF, Lin FC, Hsu CK, Sun IT, Chang SC, Tsai CY, Lai CC. Cytomegaloviral or Pneumocystis Jiroveci Pneumonia Increases Mortality in Systemic Lupus Erythematosus Patients with Pulmonary Hemorrhage: Evidence from Bronchoalveolar Lavage Fluid. J Rheumatol 2018; 46:251-258. [PMID: 30504509 DOI: 10.3899/jrheum.180104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the role of cytomegaloviral or Pneumocystis jiroveci pneumonia (CMV/PJP) in systemic lupus erythematosus (SLE) patients with pulmonary hemorrhage (PH). METHODS We retrospectively examined hospital records for 27 SLE patients with PH who received bronchoalveolar lavage fluid (BALF) analyses. Clinical profile and mortality rates were compared between groups with and without CMV/PJP. Risk factors for PH-related mortality were analyzed. RESULTS Among 27 SLE patients with PH, 15 had pathogens from BALF samples, and 8 had CMV/PJP. Although CMV/PJP was treated, the RR for 90- and 180-day mortality rates of SLE patients with CMV/PJP were higher than those without these infections (5.94, 95% CI 1.44-24.48; 7.13, 95% CI 1.81-28.06, respectively). Risk factors for 90- and 180-day mortality were presence of CMV/PJP (OR 14.2, 95% CI 1.83-109.9; OR 25.5, 95% CI 2.91-223.3, respectively) and use of pulse methylprednisolone for PH treatment (OR 12.0, 95% CI 1.48-97.2; OR 8.5, 95% CI 1.13-63.9, respectively). Factors increasing the 90-day mortality rate were duration of mechanical ventilation exceeding 14 days (OR 11.1, 95% CI 1.11-112.0) and use of aggressive immunosuppression close to PH onset (OR 7.56, 95% CI 1.09-52.4). Three of the 7 patients receiving aggressive immunosuppression died with the presence of CMV/PJP. CONCLUSION Owing to the high prevalence of CMV/PJP and its association with mortality, routine BALF analysis is recommended for all suitable SLE patients with PH. Use of aggressive immunosuppression does not benefit SLE patients with opportunistic infections during PH attack.
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Affiliation(s)
- Yi-Syuan Sun
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - De-Feng Huang
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - Fang-Chi Lin
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - Chih-Kai Hsu
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - I-Ting Sun
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - Shi-Chuan Chang
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - Chang-Youh Tsai
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan.,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University
| | - Chien-Chih Lai
- From the Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei City; Faculty of Medicine, National Yang-Ming University, Taiwan and Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan. .,Y.S. Sun, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; D.F. Huang, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; F.C. Lin, MD, PhD, Department of Chest Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.K. Hsu, MD, Department of Chest Medicine, Taipei Veterans General Hospital Yuli Branch; I.T. Sun, MD, Department of Ophthalmology, E-Da Hospital, I-Shou University; S.C. Chang, MD, PhD, Professor, Department of Chest Medicine, Taipei Veterans General Hospital, and Institute of Emergency and Critical Care Medicine, National Yang-Ming University; C.Y. Tsai, MD, PhD, Professor, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, National Yang-Ming University; C.C. Lai, MD, Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, and Faculty of Medicine, and Institute of Clinical Medicine, National Yang-Ming University.
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22
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Blay G, Rodrigues JC, Ferreira JCO, Leal GN, Gormezano NW, Novak GV, Pereira RMR, Terreri MT, Magalhães CS, Molinari BC, Sakamoto AP, Aikawa NE, Campos LMA, Fernandes TAP, Clemente G, Peracchi OAB, Bugni V, Marini R, Sacchetti SB, Carvalho LM, Fraga MM, Castro TCM, Ramos VC, Bonfá E, Silva CA. Diffuse alveolar hemorrhage in childhood-onset systemic lupus erythematosus: a severe disease flare with serious outcome. Adv Rheumatol 2018; 58:39. [PMID: 30657099 DOI: 10.1186/s42358-018-0038-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/16/2018] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To evaluate prevalence, clinical manifestations, laboratory abnormalities and treatment in a multicenter cohort study including 847 childhood-onset systemic lupus erythematosus (cSLE) patients with and without diffuse alveolar hemorrhage (DAH), as well as concomitant parameters of severity. METHODS DAH was defined as the presence of at least three respiratory symptoms/signs associated with diffuse interstitial/alveolar infiltrates on chest x-ray or high-resolution computer tomography and sudden drop in hemoglobin levels. Statistical analysis was performed using Bonferroni correction (p < 0.0022). RESULTS DAH was observed in 19/847 (2.2%) cSLE patients. Cough/dyspnea/tachycardia/hypoxemia occurred in all cSLE patients with DAH. Concomitant parameters of severity observed were: mechanical ventilation in 14/19 (74%), hemoptysis 12/19 (63%), macrophage activation syndrome 2/19 (10%) and death 9/19 (47%). Further analysis of cSLE patients at DAH diagnosis compared to 76 cSLE control patients without DAH with same disease duration [3 (1-151) vs. 4 (1-151) months, p = 0.335], showed higher frequencies of constitutional involvement (74% vs. 10%, p < 0.0001), serositis (63% vs. 6%, p < 0.0001) and sepsis (53% vs. 9%, p < 0.0001) in the DAH group. The median of disease activity score(SLEDAI-2 K) was significantly higher in cSLE patients with DAH [18 (5-40) vs. 6 (0-44), p < 0.0001]. The frequencies of thrombocytopenia (53% vs. 12%, p < 0.0001), intravenous methylprednisolone (95% vs. 16%, p < 0.0001) and intravenous cyclophosphamide (47% vs. 8%, p < 0.0001) were also significantly higher in DAH patients. CONCLUSIONS This was the first study to demonstrate that DAH, although not a disease activity score descriptor, occurred in the context of significant moderate/severe cSLE flare. Importantly, we identified that this condition was associated with serious disease flare complicated by sepsis with high mortality rate.
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Affiliation(s)
- Gabriela Blay
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil.,Pediatric Pulmonology Unit, Children's Institute, FMUSP, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Joaquim C Rodrigues
- Pediatric Pulmonology Unit, Children's Institute, FMUSP, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Juliana C O Ferreira
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Gabriela N Leal
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | | | - Glaucia V Novak
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | | | - Maria T Terreri
- Pediatric Rheumatology Unit, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Claudia S Magalhães
- São Paulo State University (UNESP), Faculdade de Medicina de Botucatu, Sao Paulo, Brazil
| | - Beatriz C Molinari
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Ana P Sakamoto
- Pediatric Rheumatology Unit, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Nadia E Aikawa
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil.,Division of Rheumatology, FMUSP, Sao Paulo, Brazil
| | - Lucia M A Campos
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Taciana A P Fernandes
- São Paulo State University (UNESP), Faculdade de Medicina de Botucatu, Sao Paulo, Brazil
| | - Gleice Clemente
- Pediatric Rheumatology Unit, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Octavio A B Peracchi
- Pediatric Rheumatology Unit, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Vanessa Bugni
- Pediatric Rheumatology Unit, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Roberto Marini
- São Paulo State University of Campinas (UNICAMP), Sao Paulo, Brazil
| | | | - Luciana M Carvalho
- Ribeirão Preto Medical School - University of São Paulo, Sao Paulo, Brazil
| | | | | | - Valéria C Ramos
- Pontifical Catholic University of Sorocaba, Sao Paulo, Brazil
| | - Eloisa Bonfá
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Clovis A Silva
- Pediatric Rheumatology Unit, Children's Institute, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil. .,Pediatric Pulmonology Unit, Children's Institute, FMUSP, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil.
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Pilania RK, Suri D, Jindal AK, Kumar N, Sharma A, Sharma P, Guleria S, Rawat A, Ahluwalia J, Singh S. Lupus anticoagulant hypoprothrombinemia syndrome associated with systemic lupus erythematosus in children: report of two cases and systematic review of the literature. Rheumatol Int 2018; 38:1933-1940. [PMID: 30099593 DOI: 10.1007/s00296-018-4127-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 08/06/2018] [Indexed: 12/13/2022]
Abstract
We report two children with systemic lupus erythematosus (SLE) having severe bleeding manifestations and lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) along with a review of published cases of childhood SLE and LAHPS. We report clinical and laboratory profile of two children diagnosed with childhood SLE and LAHPS. We also conducted literature search to identify similar published cases and a review was performed. An 8-year-old girl had presented with fever, arthralgia, alopecia, anasarca and bleeding from multiple sites. She was diagnosed to have SLE based on laboratory investigations which showed anemia, thrombocytopenia, low complements, positive anti-nuclear antibody (ANA) and double standard DNA (dsDNA) antibodies. She was also found to have prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), positive lupus anticoagulant (LA) and low factor II levels. She was diagnosed to have SLE with LAHPS and treated with intravenous methylprednisolone, intravenous immunoglobulin and cyclophosphamide with good outcome. Patient 2 was a 7-year-old-boy who was diagnosed to have SLE when he presented with fever, anasarca, malar rash, arthritis and bleeding from skin and mucosa. Laboratory investigations revealed anemia, proteinuria, low complements, positive ANA and anti-dsDNA titre. Coagulation studies showed deranged PT and aPTT, positive LA and low factor II levels. He was diagnosed to have SLE with LAHPS and was treated with intravenous methylprednisolone and oral mycophenolate mofetil. Review of literature of cases with childhood SLE and LAHPS showed that there are 32 cases have been reported till date which have been summarized. LAHPS is an uncommonly identified cause of bleeding in patients with SLE and must be suspected while evaluating these children.
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Affiliation(s)
- Rakesh Kumar Pilania
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Deepti Suri
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Ankur Kumar Jindal
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Narender Kumar
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Avinash Sharma
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Praveen Sharma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandesh Guleria
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Amit Rawat
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Jasmina Ahluwalia
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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24
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Wang CR, Liu MF, Weng CT, Lin WC, Li WT, Tsai HW. Systemic lupus erythematosus-associated diffuse alveolar haemorrhage: a single-centre experience in Han Chinese patients. Scand J Rheumatol 2018; 47:392-399. [PMID: 29916287 DOI: 10.1080/03009742.2017.1420817] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Despite aggressive therapeutic regimens, diffuse alveolar haemorrhage (DAH) is still associated with a high mortality rate in systemic lupus erythematosus (SLE). This study was carried out in patients with SLE-associated DAH with a focus on their therapeutic modality. METHOD A retrospective review was performed in 839 Han Chinese lupus patients hospitalized for their DAH manifestation from May 2006 to December 2016. RESULTS There were 24 episodes in 17 cases (2.0% incidence), 15 females and two males aged 19-67 years (mean ± sd 38.2 ± 15.1 years). High disease activity [Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) 12-31, 19.8 ± 5.6] was found at the onset of DAH. All patients were treated with high-dose corticosteroid, followed by pulse methylprednisolone (70.6%), plasmapheresis (41.2%), pulse cyclophosphamide (35.3%), and rituximab (23.5%). Six patients (35.3%), including three with extracorporeal membrane oxygenation, died owing to acute respiratory failure. All patients receiving rituximab treatment survived with a follow-up period of 12-58 months (40.8 ± 21.1 months), and no further relapse was noted in three cases with a history of recurrent DAH episodes. In addition, there was a significant decrease in their lupus activity (SLEDAI-2K 21.5 ± 6.0 to 6.3 ± 1.7, p = 0.0286). CONCLUSION In this single-centre series with SLE-associated DAH in Han Chinese patients, a beneficial effect of rituximab therapy was observed.
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Affiliation(s)
- C-R Wang
- a Section of Rheumatology , National Cheng Kung University Hospital , Tainan , Taiwan
| | - M-F Liu
- a Section of Rheumatology , National Cheng Kung University Hospital , Tainan , Taiwan
| | - C-T Weng
- a Section of Rheumatology , National Cheng Kung University Hospital , Tainan , Taiwan
| | - W-C Lin
- b Section of Critical Care Medicine, Department of Internal Medicine , National Cheng Kung University Hospital , Tainan , Taiwan
| | - W-T Li
- b Section of Critical Care Medicine, Department of Internal Medicine , National Cheng Kung University Hospital , Tainan , Taiwan
| | - H-W Tsai
- c Department of Pathology , National Cheng Kung University Hospital , Tainan , Taiwan
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25
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Du J, Wang Y, Li YC, Wang TT, Zhou YL, Ying ZH. Acute diffuse alveolar haemorrhage accompanied by gastrointestinal bleeding in a patient with serious systemic lupus erythematosus: A case report. J Int Med Res 2018; 46:2046-2053. [PMID: 29557269 PMCID: PMC5991244 DOI: 10.1177/0300060517749666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease that affects many organs, but multisystem dysfunction is rare. Here, we report a case of a 29-year-old woman who was initially diagnosed with SLE complications including lupus nephritis, lupus encephalopathy, renal hypertension, thrombocytopenia, anaemia and hyperkalaemia. She recovered following treatment with high dose methylprednisolone, intravenous immunoglobulin (IVIG) and continuous renal replacement therapy (CRRT). However, a few days after hospital discharge, she developed gastrointestinal bleeding. Although intensive treatment was administered, the patient deteriorated rapidly and had a progressive decline in oxygen saturation followed by diffuse alveolar haemorrhage and acute left heart failure. Inotropic therapy, mechanical ventilation, blood transfusion, CRRT, antibiotics, intravenous glucocorticoids and other support therapies were initiated and gradually the patient's vital signs stabilized and haemoptysis subsided. This case report emphasises that complications of SLE can occur at any stage of the disease, especially in patients with active SLE. Therefore, it is important for clinicians to be aware of the rare presentations of SLE and its complex management. For multisystem dysfunction, early intensive treatment with high dose corticosteroids and cyclophosphamide is advocated.
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Affiliation(s)
- Jing Du
- Department of Laboratory Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China
| | - Ying Wang
- Department of Transfusion Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yan-chun Li
- Department of Pathology, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Tong-Tong Wang
- The Second Clinical Medical College, Zhejiang Chinese Medicine University, Hangzhou, China
| | - Yong-lie Zhou
- Department of Laboratory Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China
- Zhen-hua Ying and Yong-lie Zhou, Zhejiang Provincial People’s Hospital, Hangzhou, 310014, Zhejiang, China; Zhejiang Provincial People’s Hospital, Hangzhou, 310014, Zhejiang, China. Emails: ;
| | - Zhen-hua Ying
- Department of Rheumatology and Immunology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China
- Zhen-hua Ying and Yong-lie Zhou, Zhejiang Provincial People’s Hospital, Hangzhou, 310014, Zhejiang, China; Zhejiang Provincial People’s Hospital, Hangzhou, 310014, Zhejiang, China. Emails: ;
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A fatal case of diffuse alveolar hemorrhage as the initial presentation of systemic lupus erythematosus: A case report and literature review. Respir Med Case Rep 2018; 24:55-57. [PMID: 29977760 PMCID: PMC6010613 DOI: 10.1016/j.rmcr.2018.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 04/12/2018] [Accepted: 04/12/2018] [Indexed: 02/04/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare fatal pulmonary complication of systemic lupus erythematosus (SLE). The clinical syndrome is characterized by hemoptysis, acute fall in hematocrit, hypoxemic respiratory failure, and diffuses pulmonary infiltrates. We describe a case of 23-year-old female who presented with Ludwig's angina that was complicated by diffuse alveolar hemorrhage as the initial presentation of undiagnosed systemic lupus erythematosus. A high index of suspicion is need for prompt diagnosis and treatment in order to avoid the high mortality associated with such cases.
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Martínez-Martínez MU, Oostdam DAHV, Abud-Mendoza C. Diffuse Alveolar Hemorrhage in Autoimmune Diseases. Curr Rheumatol Rep 2017; 19:27. [PMID: 28397125 DOI: 10.1007/s11926-017-0651-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The present paper establishes a narrative and analytical review of diffuse alveolar hemorrhage (DAH) in ANCA-associated vasculitis, systemic lupus erythematosus, and antiphospholipid syndrome. RECENT FINDINGS Recent studies found a frequent association between DAH and infections and systemic lupus erythematosus and its associated factors. Biological therapies like rituximab have demonstrated benefit mainly in patients with ANCA-associated vasculitis. Main clinical manifestations of diffuse alveolar hemorrhage in these three diseases include dyspnea, pulmonary infiltrates, cough, and hypoxemia. The presence of hemorrhagic bronchoalveolar lavage, hemosiderin containing macrophages, or an increase of carbon monoxide diffusing capacity have been described in some series as helpful findings for the diagnosis. Hemoptysis has been seen mainly in systemic lupus erythematosus. The cornerstone of therapy includes glucocorticoids and cyclophosphamide, and recent findings in ANCA-associated vasculitis suggest the similar benefit of rituximab. Future evaluations and systematic reviews will help to define the real benefit for therapies that appeared to be controversial at the moment.
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Affiliation(s)
- Marco Ulises Martínez-Martínez
- Faculty of Medicine, Universidad Autónoma San Luis Potosí and Hospital Central "Dr. Ignacio Morones Prieto", Avenida Venustiano Carranza 2395, Zona Universitaria, 78290, San Luis Potosí, San Luis Potosí, Mexico
- Hospital General de Zona No. 1, Instituto Mexicano del Seguro Social, San Luis Potosí, San Luis Potosí, Mexico
| | - David Alejandro Herrera-van Oostdam
- Faculty of Medicine, Universidad Autónoma San Luis Potosí and Hospital Central "Dr. Ignacio Morones Prieto", Avenida Venustiano Carranza 2395, Zona Universitaria, 78290, San Luis Potosí, San Luis Potosí, Mexico
- Hospital General de Zona No. 50, Instituto Mexicano del Seguro Social, San Luis Potosí, San Luis Potosí, Mexico
| | - Carlos Abud-Mendoza
- Faculty of Medicine, Universidad Autónoma San Luis Potosí and Hospital Central "Dr. Ignacio Morones Prieto", Avenida Venustiano Carranza 2395, Zona Universitaria, 78290, San Luis Potosí, San Luis Potosí, Mexico.
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Kim D, Choi J, Cho SK, Choi CB, Kim TH, Jun JB, Yoo DH, Bae SC, Sung YK. Clinical characteristics and outcomes of diffuse alveolar hemorrhage in patients with systemic lupus erythematosus. Semin Arthritis Rheum 2017; 46:782-787. [DOI: 10.1016/j.semarthrit.2016.09.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 09/05/2016] [Accepted: 09/08/2016] [Indexed: 02/06/2023]
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Diffuse Alveolar Hemorrhage in Systemic Lupus Erythematosus: Histopathologic Features and Clinical Correlations. Case Rep Pathol 2017; 2017:1936282. [PMID: 28536665 PMCID: PMC5425825 DOI: 10.1155/2017/1936282] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/28/2017] [Accepted: 04/10/2017] [Indexed: 12/04/2022] Open
Abstract
The case of a 16-year-old African-American girl with systemic lupus erythematosus, who developed diffuse alveolar hemorrhage with fatal consequences, is described. Diffuse alveolar hemorrhage is a rare but serious complication of systemic lupus. It occurs in three distinct but overlapping phenotypes, acute capillaritis, bland pulmonary hemorrhage, and diffuse alveolar damage, each of which is associated with a different group of underlying conditions. Diffuse alveolar hemorrhage is a medical emergency: choice of treatment depends on early diagnosis and determination of the underlying etiology. Acute infection, superimposed on diffuse alveolar hemorrhage in the setting of immune compromise, is often a terminal event, as in this case.
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Alveolar hemorrhage as the initial presentation of systemic lupus erythematosus. Reumatologia 2016; 54:264-266. [PMID: 27994272 PMCID: PMC5149575 DOI: 10.5114/reum.2016.63668] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 10/28/2016] [Indexed: 01/08/2023] Open
Abstract
Alveolar hemorrhage (AH) is a rare syndrome that can often occur in autoimmune diseases, blood clotting disorders, infection or by acute inhalation injury, presenting rapid evolution and high mortality, especially with late diagnosis and treatment. Among the autoimmune diseases, there are reported cases in patients with primary antiphospholipid syndrome (PAPS), vasculitis and systemic lupus erythematosus (SLE). An early diagnosis is an essential tool in the successful management of this complication, requiring aggressive treatment based on vigorous immunosuppression and broad-spectrum antibiotic. We describe here a case of alveolar hemorrhage associated with glomerulonephritis as the open presentation in a patient with SLE.
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Singla S, Canter DL, Vece TJ, Muscal E, DeGuzman M. Diffuse Alveolar Hemorrhage as a Manifestation of Childhood-Onset Systemic Lupus Erythematosus. Hosp Pediatr 2016; 6:496-500. [PMID: 27390368 DOI: 10.1542/hpeds.2015-0281] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is a devastating clinical syndrome characterized by a falling hematocrit, respiratory insufficiency, and radiographic evidence of pulmonary infiltrates. Literature regarding management of DAH in childhood-onset SLE (cSLE) is limited. METHODS We reviewed the presentation, management, and outcome of DAH in a pediatric tertiary medical center with one of the largest cSLE cohorts in North America. During a 10 year period 7 of 410 children with cSLE had DAH. RESULTS The majority of cSLE patients with DAH were male (71%) and Hispanic (57%). The median age at the time of DAH diagnosis was 14 years (range 3 -15 years). DAH was the presenting manifestation of cSLE in 29% of children; 71% presented with DAH within 3 months of their diagnosis. All patients had cough, 86% had dyspnea, and 29% had hemoptysis. All patients had anemia and 71% had thrombocytopenia. Eighty-six percent had hematuria/proteinuria, and a positive anti-double stranded DNA antibody. Chest imaging showed diffuse ground glass opacities in all events. All patients developed respiratory insufficiency (29% supplemental oxygenation and 71% mechanical ventilation). Transfusions were required in 57% of cases. All patients received corticosteroids and additional immunomodulation to achieve disease control. Eighty-six percent of our DAH/cSLE cohort survived their initial event (median follow-up 2.5 years). No survivor required supplemental oxygen or had a DAH recurrence. CONCLUSIONS SLE should be in the hospitalist's differential diagnosis for any child with respiratory insufficiency, cytopenias, and/or urinary abnormalities. Once cSLE is identified, initiation of aggressive immune suppression with multiple agents may enhance outcomes.
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Affiliation(s)
- Saimun Singla
- Division of Allergy, Immunology, and Rheumatology, Texas Children's Hospital, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas; and
| | - Debra L Canter
- Division of Allergy, Immunology, and Rheumatology, Texas Children's Hospital, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas; and
| | - Timothy J Vece
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; and Division of Pulmonology, Texas Children's Hospital, Houston, Texas
| | - Eyal Muscal
- Division of Allergy, Immunology, and Rheumatology, Texas Children's Hospital, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas; and
| | - Marietta DeGuzman
- Division of Allergy, Immunology, and Rheumatology, Texas Children's Hospital, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas; and
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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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Loyola Rodriguez JP, Galvan Torres LJ, Martinez Martinez RE, Abud Mendoza C, Medina Solis CE, Ramos Coronel S, Garcia Cortes JO, Domínguez Pérez RA. Frequency of dental caries in active and inactive systemic lupus erythematous patients: salivary and bacterial factors. Lupus 2016; 25:1349-56. [PMID: 27053402 DOI: 10.1177/0961203316640909] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 02/27/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The objective of this study was to determine dental caries frequency and to analyze salivary and bacterial factors associated with active and inactive systemic lupus erythematous (SLE) patients. Also, a proposal to identify dental caries by a surface, teeth, and the patient was developed. MATERIAL AND METHODS A cross-sectional, blinded study that included 60 SLE patients divided into two groups of 30 subjects each, according to the Activity Index for Diagnosis of Systemic Lupus Erythematous (SLEDAI). The decayed, missing, and filled teeth (DMFT) index and Integrative Dental Caries Index (IDCI) were used for analyzing dental caries. The saliva variables recorded were: flow, pH, and buffer capacity. The DNA copies of Streptococcus mutans and Streptococcus sobrinus were estimated by real-time PCR. RESULTS The caries frequency was 85% for SLE subjects (73.3% for inactive systemic lupus erythematous (ISLE) and 100% for active systemic lupus erythematous (ASLE)); DMFT for the SLE group was 12.6 ± 5.7 and the IDCI was (9.8 ± 5.9). The ASLE group showed a salivary flow of 0.65 compared with 0.97 ml/1 min from the ISLE group; all variables mentioned above showed a statistical difference (p < 0.05). The salivary pH was 4.6 (6.06 for ISLE and 3.9 for ASLE). The DNA copies of S. mutans and S. sobrinus were high; all variables mentioned above show a significant statistical difference (p < 0.05) between groups. CONCLUSION SLE patients had high DMFT and IDCI scores that were associated with a decrease in salivary flow, pH, and buffer capacity. There were high counts of S. sobrinus and S. mutans species, and IDCI is a useful tool to provide more detail about dental caries in epidemiological studies.
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Affiliation(s)
- J P Loyola Rodriguez
- Advanced Education in General Dentistry, Master Degree Program at San Luis Potosi University, Mexico
| | - L J Galvan Torres
- Advanced Education in General Dentistry, Master Degree Program at San Luis Potosi University, Mexico
| | - R E Martinez Martinez
- Advanced Education in General Dentistry, Master Degree Program at San Luis Potosi University, Mexico
| | - C Abud Mendoza
- Regional Unit of Rheumatology and Osteoporosis at Central Hospital "Dr. Ignacio Morones Prieto", Faculty of Medicine, San Luis Potosi University, Mexico
| | | | - S Ramos Coronel
- Advanced Education in General Dentistry, Master Degree Program at San Luis Potosi University, Mexico
| | - J O Garcia Cortes
- Advanced Education in General Dentistry, Master Degree Program at San Luis Potosi University, Mexico
| | - R A Domínguez Pérez
- Doctorado en Ciencias Biomédicas Básicas, Facultad de Medicina, Universidad Autónoma de San Luis Potosí University, Mexico
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Kazzaz NM, Coit P, Lewis EE, McCune WJ, Sawalha AH, Knight JS. Systemic lupus erythematosus complicated by diffuse alveolar haemorrhage: risk factors, therapy and survival. Lupus Sci Med 2015; 2:e000117. [PMID: 26430514 PMCID: PMC4586940 DOI: 10.1136/lupus-2015-000117] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 08/14/2015] [Accepted: 08/28/2015] [Indexed: 01/09/2023]
Abstract
Objectives While diffuse alveolar haemorrhage (DAH) is recognised as a life-threatening complication of systemic lupus erythematosus (SLE), little is known about its risk factors and response to treatment. We describe 22 cases of DAH in a US lupus cohort of approximately 1000 patients, and compare them to 66 controls from the same outpatient cohort. Methods We captured variables pertaining to diagnoses of SLE and secondary antiphospholipid syndrome (APS), and analysed them by univariate testing. Those variables with p values <0.05 were then further considered in a multivariate model. Kaplan-Meier curves were constructed for each group, and survival was analysed by Log-rank test. Results Of the 22 patients with DAH, 59% were diagnosed with DAH within 5 years of lupus diagnosis. By univariate testing, several manifestations of SLE and APS were more common in patients with DAH, including history of thrombocytopenia, cardiac valve disease, low C3, leucopenia, neuropsychiatric features, haemolysis, arterial thrombosis, lupus anticoagulant, secondary APS and low C4. On multivariate analysis, history of thrombocytopenia and low C3 were maintained as independent risk factors. Importantly, only two patients had platelet counts <50 000/µL at the time of the DAH episode, arguing that DAH was not simply a haemorrhagic complication of thrombocytopenia. All patients were treated with increased immunosuppression, including various combinations of corticosteroids, plasmapheresis, cyclophosphamide, rituximab and mycophenolate mofetil. Notably, all patients in the cohort survived their initial episode of DAH. While the patients with DAH did well in the short-term, their long-term survival was significantly worse than controls. Several of the deaths were attributable to thrombotic complications after recovering from DAH. Conclusions To the best of our knowledge, this is the largest case–control study of lupus DAH to date. History of thrombocytopenia was strongly predictive of DAH (OR ∼40). A number of APS manifestations correlated with DAH by univariate analysis, and deserve further consideration in larger studies.
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Affiliation(s)
- Nayef M Kazzaz
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Patrick Coit
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Emily E Lewis
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - W Joseph McCune
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Amr H Sawalha
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Jason S Knight
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
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Schwarz MI. A deadly complication of systemic lupus erythematosus. J Rheumatol 2015; 41:1571-2. [PMID: 25086137 DOI: 10.3899/jrheum.140613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Marvin I Schwarz
- University of Colorado Denver, Pulmonary Sciences and Critical Care Medicine, Aurora, Colorado, USA.
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Kimura D, Shah S, Briceno-Medina M, Sathanandam S, Haberman B, Zhang J, Myers L, Kumar TS, Knott-Craig C. Management of massive diffuse alveolar hemorrhage in a child with systemic lupus erythematosus. J Intensive Care 2015; 3:10. [PMID: 27213047 PMCID: PMC4874015 DOI: 10.1186/s40560-015-0076-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 02/13/2015] [Indexed: 12/18/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) from systemic lupus erythematosus (SLE) is a rare but potentially life-threatening condition. We report the case of a 14-year-old female with SLE who developed hypoxia and shock secondary to severe alveolar hemorrhage. She was successfully managed by placement on extracorporeal membrane oxygenation (ECMO) followed by emergent pulmonary lobectomy and medical treatment including high-dose methylprednisolone, cyclophosphamide, intravenous immunoglobulin, and plasmapheresis.
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Affiliation(s)
- Dai Kimura
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Le Bonheur Children's Hospital/University of Tennessee Health Science Center, 50 N. Dunlap St, TN Memphis, 38103 USA
| | - Samir Shah
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Le Bonheur Children's Hospital/University of Tennessee Health Science Center, 50 N. Dunlap St, TN Memphis, 38103 USA ; Department of ECMO/Apheresis, Le Bonheur Children's Hospital/University of Tennessee Health Science Center, 50 N. Dunlap St, Memphis, TN USA
| | - Mario Briceno-Medina
- Department of Cardiology, Le Bonheur Children's Hospital/University of Tennessee Health Science Center, 50 N. Dunlap St, Memphis, TN USA
| | - Shyam Sathanandam
- Department of Cardiology, Le Bonheur Children's Hospital/University of Tennessee Health Science Center, 50 N. Dunlap St, Memphis, TN USA
| | - Brent Haberman
- Department of Pulmonology, Le Bonheur Children's Hospital/University of Tennessee Health Science Center, 50 N. Dunlap St, Memphis, TN USA
| | - Jie Zhang
- Department of Pathology, Le Bonheur Children's Hospital/University of Tennessee Health Science Center, 50 N. Dunlap St, Memphis, TN USA
| | - Linda Myers
- Department of Rheumatology, Le Bonheur Children's Hospital/University of Tennessee Health Science Center, 50 N. Dunlap St, Memphis, TN USA
| | - Tk Susheel Kumar
- Department of Cardiovascular Surgery, Le Bonheur Children's Hospital/University of Tennessee Health Science Center, 50 N. Dunlap St, Memphis, TN USA
| | - Christopher Knott-Craig
- Department of Cardiovascular Surgery, Le Bonheur Children's Hospital/University of Tennessee Health Science Center, 50 N. Dunlap St, Memphis, TN USA
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