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Ono S, Yoshimoto K, Matsubara M, Nishimura N, Kawashima H, Yoneima R, Yada N, Nishio K. Report of Two Contrasting Cases of Epstein-Barr Virus-Associated Hemophagocytic Lymphohistiocytosis: Comparison to Infectious Mononucleosis and Flow Cytometric Analysis of Bone Marrow. Int Med Case Rep J 2024; 17:43-49. [PMID: 38269069 PMCID: PMC10807454 DOI: 10.2147/imcrj.s443996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/24/2023] [Indexed: 01/26/2024] Open
Abstract
Purpose This study aims to investigate the characteristics of Epstein-Barr virus associated-hemophagocytic lymphohistiocytosis (EBV-HLH) and HLH caused by a severe form of infectious mononucleosis (IM-HLH) compared to IM by EBV, and thus also to assist in early diagnosis and providing appropriate treatment. Methods Data for this analysis were collected from patients at the Department of General Medicine, Nara Medical University, between April 1, 2012, and August 1, 2020. EBV infection was diagnosed using clinical presentation and laboratory tests. HLH diagnosis followed the HLH-2004 protocol, supplemented by plasma EBV DNA detection. A range of clinical and laboratory parameters were collected, including age, sex, clinical outcomes, blood cell counts, hemoglobin, platelets, and various serum values. Plasma EBV DNA levels and flow cytometric analysis (FCM) of bone marrow were performed for HLH cases. Results Among 1850 hospitalized patients, 14 cases were identified, including 2 HLH cases and 12 IM cases. Comparative analysis revealed distinctive features of HLH, including lower lymphocyte and platelet counts and higher levels of ferritin, soluble interleukin 2 receptor (sIL-2R), and D dimer compared to IM. Notably, one HLH case responded well to corticosteroid monotherapy, while the other case did not, resulting in a fatal outcome. Detection of a cluster of CD5-CD7 lymphocytes in bone marrow is a hallmark of EBV-HLH and useful to distinguish from IM-HLH. Conclusion This study underscores the importance of early differentiation among EBV-HLH, IM-HLH, and IM in adults to guide appropriate treatment strategies. While specific laboratory markers help distinguish HLH from IM, a more detailed analysis of FCM is crucial for precise diagnosis of HLH cases and tailored therapeutic interventions.
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Affiliation(s)
- Shiro Ono
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Kiyomi Yoshimoto
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Masaki Matsubara
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Nobushiro Nishimura
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Hiromasa Kawashima
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Ryo Yoneima
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Noritaka Yada
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Kenji Nishio
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
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Yoshimoto K, Kaneda S, Asada M, Taguchi H, Kawashima H, Yoneima R, Matsuoka H, Tsushima E, Ono S, Matsubara M, Yada N, Nishio K. Giant Cell Arteritis after COVID-19 Vaccination with Long-Term Follow-Up: A Case Report and Review of the Literature. Medicina (Kaunas) 2023; 59:2127. [PMID: 38138230 PMCID: PMC10744572 DOI: 10.3390/medicina59122127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 11/21/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023]
Abstract
Giant cell arteritis (GCA) is a chronic vasculitis that primarily affects the elderly, and can cause visual impairment, requiring prompt diagnosis and treatment. The global impact of the coronavirus disease 2019 (COVID-19) pandemic has been substantial. Although vaccination programs have been a key defense strategy, concerns have arisen regarding post-vaccination immune-mediated disorders and related risks. We present a case of GCA after COVID-19 vaccination with 2 years of follow-up. A 69-year-old woman experienced fever, headaches, and local muscle pain two days after receiving the COVID-19 vaccine. Elevated inflammatory markers were observed, and positron emission tomography (PET) revealed abnormal uptake in the major arteries, including the aorta and subclavian and iliac arteries. Temporal artery biopsy confirmed the diagnosis of GCA. Treatment consisted of pulse therapy with methylprednisolone, followed by prednisolone (PSL) and tocilizumab. Immediately after the initiation of treatment, the fever and headaches disappeared, and the inflammation markers normalized. The PSL dosage was gradually reduced, and one year later, a PET scan showed that the inflammation had resolved. After two years, the PSL dosage was reduced to 3 mg. Fourteen reported cases of GCA after COVID-19 vaccination was reviewed to reveal a diverse clinical picture and treatment response. The time from onset of symptoms to GCA diagnosis varied from two weeks to four months, highlighting the challenge of early detection. The effectiveness of treatment varied, but was generally effective similarly to that of conventional GCA. This report emphasizes the need for clinical vigilance and encourages further data collection in post-vaccination GCA cases.
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Affiliation(s)
- Kiyomi Yoshimoto
- Department of General Medicine, Nara Medical University Hospital, Kashihara 634-8522, Nara, Japan; (S.K.); (M.A.); (H.T.); (H.K.); (R.Y.); (H.M.); (E.T.); (S.O.); (M.M.); (N.Y.); (K.N.)
| | - Saori Kaneda
- Department of General Medicine, Nara Medical University Hospital, Kashihara 634-8522, Nara, Japan; (S.K.); (M.A.); (H.T.); (H.K.); (R.Y.); (H.M.); (E.T.); (S.O.); (M.M.); (N.Y.); (K.N.)
- Department of General Medicine, Uda City Hospital, Uda 633-0298, Nara, Japan
| | - Moe Asada
- Department of General Medicine, Nara Medical University Hospital, Kashihara 634-8522, Nara, Japan; (S.K.); (M.A.); (H.T.); (H.K.); (R.Y.); (H.M.); (E.T.); (S.O.); (M.M.); (N.Y.); (K.N.)
| | - Hiroyuki Taguchi
- Department of General Medicine, Nara Medical University Hospital, Kashihara 634-8522, Nara, Japan; (S.K.); (M.A.); (H.T.); (H.K.); (R.Y.); (H.M.); (E.T.); (S.O.); (M.M.); (N.Y.); (K.N.)
| | - Hiromasa Kawashima
- Department of General Medicine, Nara Medical University Hospital, Kashihara 634-8522, Nara, Japan; (S.K.); (M.A.); (H.T.); (H.K.); (R.Y.); (H.M.); (E.T.); (S.O.); (M.M.); (N.Y.); (K.N.)
| | - Ryo Yoneima
- Department of General Medicine, Nara Medical University Hospital, Kashihara 634-8522, Nara, Japan; (S.K.); (M.A.); (H.T.); (H.K.); (R.Y.); (H.M.); (E.T.); (S.O.); (M.M.); (N.Y.); (K.N.)
| | - Hidetoshi Matsuoka
- Department of General Medicine, Nara Medical University Hospital, Kashihara 634-8522, Nara, Japan; (S.K.); (M.A.); (H.T.); (H.K.); (R.Y.); (H.M.); (E.T.); (S.O.); (M.M.); (N.Y.); (K.N.)
| | - Emiko Tsushima
- Department of General Medicine, Nara Medical University Hospital, Kashihara 634-8522, Nara, Japan; (S.K.); (M.A.); (H.T.); (H.K.); (R.Y.); (H.M.); (E.T.); (S.O.); (M.M.); (N.Y.); (K.N.)
| | - Shiro Ono
- Department of General Medicine, Nara Medical University Hospital, Kashihara 634-8522, Nara, Japan; (S.K.); (M.A.); (H.T.); (H.K.); (R.Y.); (H.M.); (E.T.); (S.O.); (M.M.); (N.Y.); (K.N.)
| | - Masaki Matsubara
- Department of General Medicine, Nara Medical University Hospital, Kashihara 634-8522, Nara, Japan; (S.K.); (M.A.); (H.T.); (H.K.); (R.Y.); (H.M.); (E.T.); (S.O.); (M.M.); (N.Y.); (K.N.)
| | - Noritaka Yada
- Department of General Medicine, Nara Medical University Hospital, Kashihara 634-8522, Nara, Japan; (S.K.); (M.A.); (H.T.); (H.K.); (R.Y.); (H.M.); (E.T.); (S.O.); (M.M.); (N.Y.); (K.N.)
| | - Kenji Nishio
- Department of General Medicine, Nara Medical University Hospital, Kashihara 634-8522, Nara, Japan; (S.K.); (M.A.); (H.T.); (H.K.); (R.Y.); (H.M.); (E.T.); (S.O.); (M.M.); (N.Y.); (K.N.)
- Department of General Medicine, Uda City Hospital, Uda 633-0298, Nara, Japan
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Nishimura N, Yoshimoto K, Yada N, Kakiwaki A, Sawa A, Senzaki S, Kawashima H, Yoneima R, Ono S, Sakai K, Matsumoto M, Fukushima H, Nishio K. The Combination of the Lactate Dehydrogenase/Hemoglobin Ratio with the PLASMIC Score Facilitates Differentiation of TTP from Septic DIC Without Identification of Schistocytes. Clin Appl Thromb Hemost 2023; 29:10760296231207629. [PMID: 37858603 PMCID: PMC10588405 DOI: 10.1177/10760296231207629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/12/2023] [Accepted: 09/27/2023] [Indexed: 10/21/2023] Open
Abstract
In some cases, differentiating thrombotic thrombocytopenic purpura (TTP) from septic disseminated intravascular coagulation (DIC) without measuring ADAMTS13 activity is critical for urgent lifesaving plasma exchange. To investigate whether PLASMIC score without identifying the presence of schistocytes, D-dimer, fibrin/fibrinogen degradation products (FDP), FDP/D-dimer ratio, prothrombin time-international normalized ratio (PT-INR), lactate dehydrogenase (LD), hemoglobin (Hb), and LD/Hb ratio are useful in differentiating patients with TTP from those with septic DIC. Retrospective analysis was conducted on the medical records of the patients with septic DIC (32 patients) or TTP (16 patients). The PLASMIC score and other laboratory measurements all were helpful in differentiating TTP from septic DIC. When dichotomized between high risk (scores 6-7) and intermediate-low risk (scores 0-5), the PLASMIC score predicted TTP with a sensitivity of 75.0% and a specificity of 100%. However, 4 of 16 patients with TTP and 19 of 32 patients with septic DIC showed comparable PLASMIC scores of 4 or 5, making it difficult to distinguish between the two by PLASMIC score alone. Among the measurements examined, the LDH/Hb ratio was the most useful for differentiation. Receiver operating characteristic analysis of the LD/Hb ratio for predicting TTP revealed a cutoff of 53.7 (IU/10 g) (sensitivity 0.94, specificity 0.91). If the LD/Hb ratio was less than 53.7, it was unlikely that the patient had TTP. A combination of the LD/Hb ratio and the PLASMIC score may be useful for distinguishing between TTP and DIC and identifying patients who need rapid plasma exchange or caplacizumab administration.
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Affiliation(s)
- Nobushiro Nishimura
- Department of General Medicine, Nara Medical University Hospital, Nara, Japan
| | - Kiyomi Yoshimoto
- Department of General Medicine, Nara Medical University Hospital, Nara, Japan
| | - Noritaka Yada
- Department of General Medicine, Nara Medical University Hospital, Nara, Japan
| | - Ayaka Kakiwaki
- Department of General Medicine, Nara Medical University Hospital, Nara, Japan
| | - Akihiro Sawa
- Department of General Medicine, Nara Medical University Hospital, Nara, Japan
| | - Satoshi Senzaki
- Department of General Medicine, Nara Medical University Hospital, Nara, Japan
| | - Hiromasa Kawashima
- Department of General Medicine, Nara Medical University Hospital, Nara, Japan
| | - Ryo Yoneima
- Department of General Medicine, Nara Medical University Hospital, Nara, Japan
| | - Shiro Ono
- Department of General Medicine, Nara Medical University Hospital, Nara, Japan
| | - Kazuya Sakai
- Department of Blood Transfusion, Nara Medical University Hospital, Nara, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion, Nara Medical University Hospital, Nara, Japan
| | - Hidetada Fukushima
- Department of Emergency and Critical Care Medicine, Nara Medical University Hospital, Nara, Japan
| | - Kenji Nishio
- Department of General Medicine, Nara Medical University Hospital, Nara, Japan
- Department of General Medicine, Uda Municipal Hospital, Nara, Japan
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Ono S, Yoshimoto K, Nishimura N, Yoneima R, Kawashima H, Kobayashi T, Tai Y, Miyamoto M, Tsushima E, Yada N, Nishio K. Complete Resolution of a Case of TAFRO Syndrome Accompanied by Mediastinal Panniculitis, Adrenal Lesion, and Liver Damage with Hyperbilirubinemia. Intern Med 2021; 60:1303-1309. [PMID: 33191324 PMCID: PMC8112990 DOI: 10.2169/internalmedicine.5850-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
TAFRO syndrome is a systemic inflammatory, lymphoproliferative disorder, but the pathophysiology of the disease is unknown. It is typically characterized by thrombocytopenia, anasarca, a fever, reticulin fibrosis, renal dysfunction, and organomegaly. However, other manifestations have been also reported. We encountered a 43-year-old man with TAFRO syndrome who showed mediastinal panniculitis, liver damage, and adrenal lesions in addition to the core signs. He achieved complete remission with combination therapy of corticosteroids, tocilizumab, and cyclosporin, and remission was maintained even after drug discontinuation at 15 months. Atypical manifestations and complete remission of TAFRO syndrome were remarkable features of our case.
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Affiliation(s)
- Shiro Ono
- Department of General Medicine, Nara Medical University, Japan
| | | | | | - Ryo Yoneima
- Department of General Medicine, Nara Medical University, Japan
| | | | | | - Yoshiaki Tai
- Department of General Medicine, Nara Medical University, Japan
| | - Makiko Miyamoto
- Department of General Medicine, Nara Medical University, Japan
| | - Emiko Tsushima
- Department of General Medicine, Nara Medical University, Japan
| | - Noritaka Yada
- Department of General Medicine, Nara Medical University, Japan
| | - Kenji Nishio
- Department of General Medicine, Nara Medical University, Japan
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Yada N, Yoshimoto K, Kawashima H, Yoneima R, Nishimura N, Tai Y, Tsushima E, Miyamoto M, Ono S, Matsumoto M, Fujimoto T, Nishio K. Plasma Level of von Willebrand Factor Propeptide at Diagnosis: A Marker of Subsequent Renal Dysfunction in Autoimmune Rheumatic Diseases. Clin Appl Thromb Hemost 2020; 26:1076029620938874. [PMID: 32705883 PMCID: PMC7383728 DOI: 10.1177/1076029620938874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction: Patients with systemic autoimmune rheumatic diseases (SARDs) such as rheumatoid arthritis, systemic lupus erythematosus (SLE), Sjögren syndrome, and systemic sclerosis, which are chronic inflammatory diseases, are prone to develop renal dysfunction, which is related to vascular endothelial cell damage. Material and Methods: We evaluated plasma levels of von Willebrand factor (VWF), VWF propeptide (VWF-pp), disintegrin-like and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), and VWF multimer pattern in patients with SARDs at diagnosis and investigated whether they may serve as markers to identify patients destined to develop renal dysfunction within 1 year. Renal dysfunction was defined as subsequent reduced estimated glomerular filtration rate (eGFR) by >25% or the new appearance of abnormal urine findings such as proteinuria (protein > 30 mg/dL) or hematuria (red blood cells >20/HPF in urine sediments). Overall, 63 patients with SARDs were studied. Results and Conclusions: We observed a significant increase of VWF-pp and a significant decrease of ADAMTS13 in patients with SARDs compared with normal healthy controls. The highest level of VWF-pp was observed in patients with SLE among the groups. The levels of VWF and multimer pattern of VWF were not different compared with normal healthy controls. Von Willebrand factor propeptide predicted a subsequent decrease in eGFR at a cutoff point of 210% (sensitivity, 78.6%; specificity, 73.5%) and new urinary abnormal findings at a cutoff point of 232% (sensitivity, 77.8%; specificity, 77.8%) Using these cutoff points, multivariable analysis revealed that VWF-pp was a significant risk factor for renal dysfunction at an odds ratio of 8.78 and 22.8, respectively, and may lead to a new therapeutic approach to prevent vasculitis and renal dysfunction.
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Affiliation(s)
- Noritaka Yada
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Kiyomi Yoshimoto
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Hiromasa Kawashima
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Ryo Yoneima
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Nobushiro Nishimura
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Yoshiaki Tai
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Emiko Tsushima
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Makiko Miyamoto
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Shiro Ono
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Masanori Matsumoto
- Department of Transfusion Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Takashi Fujimoto
- Department of Rheumatology, Nara Medical University, Kashihara, Nara, Japan
| | - Kenji Nishio
- Department of General Medicine, Nara Medical University, Kashihara, Nara, Japan
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Ono S, Kurata C, Nishimura N, Kawashima H, Yoneima R, Tai Y, Tatsumi E, Miyamoto M, Yada N, Yoshimoto K, Nishio K. Importance Of Laboratory Detection Of Macro-Aspartate Aminotransferase. Int J Gen Med 2020; 12:433-436. [PMID: 32063719 PMCID: PMC6884962 DOI: 10.2147/ijgm.s224281] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 10/30/2019] [Indexed: 12/13/2022] Open
Abstract
The macroenzyme form of aspartate aminotransferase (macro-AST) is formed by the binding of AST with immunoglobulins. Macro-AST excretion from serum is prolonged because of its high molecular weight, leading to increased AST activities. Because of the difficulty in detecting macro-AST through routine laboratory tests, affected patients often undergo repeated examinations, with associated anxiety. We report a case in which macro-AST was detected by assaying the patient’s serum after refrigeration at 4ºC for 3 days. The sample showed progressive loss of AST activity compared with that frozen in the refrigerator, indicating the presence of macro-AST, which was confirmed as a complex with IgG-κ. The cold storage method was validated using many samples obtained from several patients. Use of this simple method to detect macro-AST may avoid unnecessary examinations and patient anxiety even at primary care facilities.
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Affiliation(s)
- Shiro Ono
- Department of General Medicine, Nara Medical University, Nara, Japan
| | - Chikara Kurata
- Department of Clinical Laboratory, Nara Medical University, Nara, Japan
| | | | | | - Ryo Yoneima
- Department of General Medicine, Nara Medical University, Nara, Japan
| | - Yoshiaki Tai
- Department of General Medicine, Nara Medical University, Nara, Japan
| | - Emiko Tatsumi
- Department of General Medicine, Nara Medical University, Nara, Japan
| | - Makiko Miyamoto
- Department of General Medicine, Nara Medical University, Nara, Japan
| | - Noritaka Yada
- Department of General Medicine, Nara Medical University, Nara, Japan
| | - Kiyomi Yoshimoto
- Department of General Medicine, Nara Medical University, Nara, Japan
| | - Kenji Nishio
- Department of General Medicine, Nara Medical University, Nara, Japan
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