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Kurosawa Y, Takamura S, Wakamatsu A, Kobayashi D, Narita I. A Case of Adult-Onset Still's Disease With Hypocomplementemia. Cureus 2024; 16:e52605. [PMID: 38374851 PMCID: PMC10875399 DOI: 10.7759/cureus.52605] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 02/21/2024] Open
Abstract
Adult-onset Still's disease (AOSD) causes fever, rash, pharyngalgia, and arthralgia through autoinflammation. Its complement titer has not previously received attention because this usually increases during the inflammatory process. Our female patient in her 60s was admitted to the hospital with fever, rash, arthralgia, and pharyngalgia. Her white blood cell count was 19,130/μL, hemoglobin was 11.0 g/dL, platelet count was 26.0 × 104/μL, and ferritin titer was 6,175 ng/mL. Anti-nuclear antibodies and anti-neutrophil cytoplasmic antibodies were negative. The presence of infectious diseases and malignancies was excluded. She was diagnosed with hypocomplementemia at the onset of AOSD because of her low complement component 4 (C4) titer (<5.0 mg/dL). Her complement component 3 (C3) titer was 104.5 mg/dL, which was within normal limits. There was no sign of thrombotic microangiopathy (TMA) or hemophagocytosis. She was treated with high-dose corticosteroids, including pulse methylprednisolone therapy, cyclosporine, methotrexate, and intravenous immunoglobulin, but was resistant to these, and her disease repeatedly flared up. Treatment with intravenous cyclophosphamide eventually led to remission. Post-treatment, her C4 titer increased to within the normal range. Although hypocomplementemia with TMA or hemophagocytosis has been reported in AOSD patients, our patient showed no sign of either at disease onset. Hypocomplementemia of AOSD may be a sign of high disease activity and could be a predictive marker for resistance to standard therapy.
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Affiliation(s)
- Yoichi Kurosawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JPN
| | - Sayuri Takamura
- Department of Rheumatology, Niigata Rheumatic Center, Shibata, JPN
| | - Ayako Wakamatsu
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JPN
| | - Daisuke Kobayashi
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JPN
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JPN
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2
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Kisaoglu H, Sener S, Aslan E, Baba O, Sahin S, Bilginer Y, Kasapcopur O, Ozen S, Kalyoncu M. Impact of serological activity on flare following clinically inactive disease and remission in childhood-onset systemic lupus erythematosus. Rheumatology (Oxford) 2023:kead647. [PMID: 38048608 DOI: 10.1093/rheumatology/kead647] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/18/2023] [Accepted: 11/11/2023] [Indexed: 12/06/2023] Open
Abstract
OBJECTIVES To assess the association between serological activity (SA) and clinical inactivity in SLE and to investigate whether SA predicts flare after clinically inactive disease (CID) and remission. METHODS Longitudinal data of children from 3 paediatric rheumatology referral centres were retrospectively reviewed. CID was defined as clinical SLEDAI = 0 in patients with a prednisolone dose < 15 mg/day. A modified DORIS remission on treatment criteria was used to determine remission. RESULTS Of the 124 patients included, 89.5% displayed SA at onset. Through follow-up, the rate of SA decreased to 43.3% at first CID and 12.1% at remission. Among patients with CID, 24 (20.7%) experienced a moderate to severe flare before the attainment ofremission. While previous proliferative lupus nephritis (OR : 10.2, p: 0.01) and autoimmune haemolytic anaemia (OR : 6.4, p: 0.02) were significantly associated with an increased odds of flare after CID, SA at CID was not associated with flare. In contrast, 21 (19.6%) patients experienced a flare in a median of 18 months after remission. Hypocomplementemia (OR : 9.8, p: 0.02) and a daily hydroxychloroquine dose < 5 mg/kg (OR : 5.8, p: 0.02) at remission significantly increased the odds of flare. CONCLUSION SA increases the odds of flare at remission but not at CID. Suboptimal dosing of hydroxychloroquine should be avoided, especially in children with SA in remission to lower the risk of flares.
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Affiliation(s)
- Hakan Kisaoglu
- Division of Pediatric Rheumatology, Karadeniz Technical University Faculty of Medicine, Trabzon, TURKEY
| | - Seher Sener
- Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, TURKEY
| | - Esma Aslan
- Division of Pediatric Rheumatology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, TURKEY
| | - Ozge Baba
- Division of Pediatric Rheumatology, Karadeniz Technical University Faculty of Medicine, Trabzon, TURKEY
| | - Sezgin Sahin
- Division of Pediatric Rheumatology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, TURKEY
| | - Yelda Bilginer
- Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, TURKEY
| | - Ozgur Kasapcopur
- Division of Pediatric Rheumatology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, TURKEY
| | - Seza Ozen
- Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, TURKEY
| | - Mukaddes Kalyoncu
- Division of Pediatric Rheumatology, Karadeniz Technical University Faculty of Medicine, Trabzon, TURKEY
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Shende P, Reddy A, Vikhe VB, Faruqi AA, Khandol D. A Case of Acquired Angioedema Leading to the Diagnosis of Systemic Lupus Erythematosus. Cureus 2023; 15:e50054. [PMID: 38186529 PMCID: PMC10768937 DOI: 10.7759/cureus.50054] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
We describe a case of a young 32-year-old Indian female who presented with a solitary symptom of facial swelling for two months. The patient's blood test results showed hypocomplementemia and C1 INH deficiency and fell into the "third type" of acquired angioedema (AAE), leading to the diagnosis of systemic lupus erythematosus (SLE), with SLE inactivity at the time of presentation, which makes this an interesting case due to the rarity of such findings in our clinical settings.
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Affiliation(s)
- Prakash Shende
- General Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Avani Reddy
- General Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Vikram B Vikhe
- General Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Ahsan A Faruqi
- General Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Devansh Khandol
- General Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
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Ohta R, Sano C. Diagnosis of Rheumatoid Vasculitis From Ischemic Change in Hands: A Case Report. Cureus 2023; 15:e48962. [PMID: 38111434 PMCID: PMC10726098 DOI: 10.7759/cureus.48962] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2023] [Indexed: 12/20/2023] Open
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory disorder with a wide clinical heterogeneity. Among its complications, rheumatoid vasculitis (RV) is notable for its severity and potential to involve multiple organ systems. A particularly serious manifestation of RV is ischemia, which is indicative of advanced vasculitic involvement and a significant risk of tissue damage. This case report describes an 83-year-old male with RA who presented with polyarticular joint pain and hand ischemia. Despite the initial diagnosis of RA exacerbation, worsening systemic symptoms without identifiable infectious causes and hypocomplementemia led to the diagnosis of RV exacerbation. Initial management with steroids showed temporary improvement. However, relapse after dose reduction prompted the administration of rituximab, an anti-cluster-of-differentiate-20 (anti-CD20) monoclonal antibody, which yielded favorable outcomes. This case underscores the importance of clinical vigilance in older patients with RA for signs, such as ischemic hands, emphasizing the pivotal role of early detection and intervention in RV management, particularly in community hospital settings.
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Affiliation(s)
| | - Chiaki Sano
- Community Medicine Management, Shimane University Faculty of Medicine, Izumo, JPN
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Chen Y, Xiao C, Liao Y, Tan L. Risk Factors Analysis for the Development of Hypocomplementemia in Rheumatoid Arthritis Patients: A Single-Center Retrospective Study. Int J Gen Med 2023; 16:3583-3592. [PMID: 37614553 PMCID: PMC10443684 DOI: 10.2147/ijgm.s422547] [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: 05/30/2023] [Accepted: 08/08/2023] [Indexed: 08/25/2023] Open
Abstract
Objective The purpose of the research was to explore the possible risk factors for the development of hypocomplementemia (HC) in rheumatoid arthritis (RA) patients by analyzing their clinical and laboratory features. Methods This retrospective research contained 501 RA patients, divided into RA patients with HC (n=78) and RA patients without HC (n=423). Demographic characteristics and laboratory test results of RA patients were collected and analyzed, such as age, sex, anti-mutated citrullinated vimentin antibody (Anti-MCV), serum complements (C3, C4), immunoglobulins (IgA, IgG, IgM), hemoglobin (Hb), platelets (PLT) and erythrocyte sedimentation rate (ESR), etc. Spearman correlation was served as assessing the correlations of the levels of serum C3 and C4 with each index. Receiver operating characteristic (ROC) curves were served as assessing the diagnostic efficacy of each index for RA patients with HC. Furthermore, risk factors for the occurrence of HC in RA patients were analyzed by employing binary logistic regression of single and multiple factors. Results Compared RA patients with HC to without HC, the former were older and had a longer disease duration with increased levels of Anti-MCV, IgM and DAS28 and lower levels of Hb, PLT and ESR; Spearman correlation analysis verified the level of serum Anti-MCV was a negative correlation with C3 (r=-0.156); the area under the ROC curve (AUC) of PLT in diagnosing RA patients with HC was the largest at 0.65 (95% CI: 0.60-0.69); binary logistic regression analysis indicated that advanced age (>66 years), long disease duration (>62 months), high DAS28 value (>6.13), the levels of Anti-MCV>107.68IU/mL, IgM>1.54g/L, ESR≤69.00mm/h, Hb≤99.00g/L and PLT≤305.00×109/L were probable risk factors for the occurrence of HC in RA patients. Conclusion Age and disease duration, DAS28, Anti-MCV, IgM, ESR, Hb, and PLT are closely related to the development of HC in RA patients. Timely monitoring of these indicators can help to evaluate disease activity of RA patients and further improve their prognosis.
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Affiliation(s)
- Yinyi Chen
- Department of Clinical Laboratory, Jiangxi Province Key Laboratory of Laboratory Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Chunlan Xiao
- Department of Clinical Laboratory, The First Affiliated Hospital of University of South China, Hengyang, Hunan, People's Republic of China
| | - Yubin Liao
- Department of Clinical Laboratory, The First Affiliated Hospital of University of South China, Hengyang, Hunan, People's Republic of China
| | - Liming Tan
- Department of Clinical Laboratory, Jiangxi Province Key Laboratory of Laboratory Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
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Kisaoglu H, Baba O, Kalyoncu M. Significance of the weighted complement domain of the EULAR/ACR classification criteria in juvenile onset systemic lupus erythematosus. Lupus 2023; 32:756-762. [PMID: 37069477 DOI: 10.1177/09612033231171343] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVE We aimed to compare the clinical and laboratory characteristics of patients with SLE according to the weighted complement status of the EULAR/ACR criteria and investigate whether different weighting of the complement status at disease onset is associated with outcomes. METHODS Patients diagnosed with juvenile onset SLE who fulfilled the 2019 EULAR/ACR classification criteria were retrospectively analyzed. RESULTS Among 43 patients included, hypocomplementemia was observed in 37 (86%), mostly with a low level of both complement C3 (C3) and complement C4 (C4) (53.5%). In patients with low levels of both C3 and C4, more common cutaneous (65.2% vs 28.6%, p: 0.045), musculoskeletal involvement (78.3% vs 42.9%, p: 0.039), autoimmune hemolytic anemia (52.2% vs 14.3%, p: 0.035), positive anti-dsDNA (65.2% vs 21.4%, p: 0.017) and anti-Sm antibodies (60.9% vs 21.4%, p: 0.04) were observed. In addition these patients had higher scores from the 2019 EULAR/ACR classification criteria (26 vs 15.5, p: < 0.0001). Remission and flare rates, and SLE associated damage were not differed according to the complement status in patients with hypocomplementemia. CONCLUSION Observation of more frequent clinical and serological activity with higher total scores from the EULAR/ACR classification criteria supported the higher scoring of patients with low C3 and C4 in the weighted criteria. However, since significant number of patients did not exhibit low complement C4, and the frequency of kidney involvement did not differ according to the weighted complement status, complement C3 might be suggested as a more important diagnostic tool in patients with juvenile onset SLE. Also, weighted complement status at onset did not seem to affect the disease outcomes.
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Affiliation(s)
- Hakan Kisaoglu
- Faculty of Medicine, Department of Pediatric Rheumatology, Karadeniz Technical University, Trabzon, Turkey
| | - Ozge Baba
- Faculty of Medicine, Department of Pediatric Rheumatology, Karadeniz Technical University, Trabzon, Turkey
| | - Mukaddes Kalyoncu
- Faculty of Medicine, Department of Pediatric Rheumatology, Karadeniz Technical University, Trabzon, Turkey
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Muacevic A, Adler JR. Cryptococcal Neoformans and Varicella Zoster Meningitis in a Patient With Selective Innate Immunodeficiency: A Case Report. Cureus 2023; 15:e33490. [PMID: 36756011 PMCID: PMC9902066 DOI: 10.7759/cureus.33490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2023] [Indexed: 01/09/2023] Open
Abstract
Cryptococcal neoformans (C. neoformans) and varicella-zoster (VZV) meningitis are opportunistic infections that are primarily seen in immunocompromised patients, including those with HIV, cancer, or receiving transplants. Despite treatment, infection in immunocompromised patients can be lethal, including those with T-cell dysfunction or deficiency. Whether innate immunodeficiencies also predispose to these infections remains less clear. Here, we report a case of disseminated C. neoformans and VZV meningitis in a young male with idiopathic hypereosinophilic syndrome and hypocomplementemia and no history of HIV infection, malignancy, or transplant. The patient presented with a pulsating headache, myalgia, joint pain, insomnia, night sweats, and subjective fever, along with clusters of vesicular lesions on his neck and back. A lumbar puncture and an MRI of the brain confirmed C. neoformans and VZV meningitis. Vesicular skin lesions proved to be VZV, and blood culture confirmed fungemia, suggesting disseminated disease. We investigated his medical history further to determine the underlying cause of his prior hypereosinophilia and current meningitis. The patient had idiopathic hypereosinophilia with high IgE levels, low complement levels, high rheumatoid factor levels, and an intermittent rash dating back two years, which had been treated intermittently with prednisone and hydroxyurea, with the most recent admission three weeks prior to this admission. Prior to admission, the patient had a peak absolute eosinophil count of 18.6 x103/uL. The patient was discharged on a daily dose of 60 mg of prednisone without hydroxyurea. In further evaluating his immune status, we found he was HIV-negative, with a normal CD4 count and high IgE. We also tested lymphocyte subsets and proliferation, which showed a low CD16/56 level, suggesting possibly reduced natural killer (NK) cell quantity. The patient responded well to acyclovir, amphotericin, and flucytosine therapy. After follow-up cerebrospinal fluid (CSF) and blood cultures were negative, the patient was discharged with fluconazole as maintenance therapy.
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Bieber A, Markovits D, Toledano K, Tavor Y, Mader R, Balbir-Gurman A, Braun-Moscovici Y. Hypocomplementemia during tocilizumab treatment: Long-term follow-up results. Medicine (Baltimore) 2022; 101:e29528. [PMID: 35713462 PMCID: PMC9276208 DOI: 10.1097/md.0000000000029528] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 05/09/2022] [Indexed: 11/27/2022] Open
Abstract
Hypocomplementemia has been reported in patients with rheumatoid arthritis treated with tocilizumab (TCZ), but its long-term consequences are unknown. We assessed the long-term outcome of patients treated with TCZ who developed hypocomplementemia regarding serious bacterial infections or autoimmune diseases (AID).The charts of patients treated with TCZ at two rheumatology centers were reviewed retrospectively. Data regarding patients' age, gender, disease duration, autoantibodies status, previous or concomitant treatments, blood counts, liver enzymes, C3 and C4 levels at baseline and during TCZ treatment, episodes of infections, allergic reactions, and AID were analyzed. Univariate analysis was used to compare patients with low C3, C4 levels versus patients with normal C3, C4 levels. Variables that were statistically significant associated or tended to be associated with low C3 or C4 were included in multiple variable logistic regression.Of 132 patients treated with TCZ, 108 had serial measurements of serum complement concentration. Thirty-three (30%) patients developed low C4 levels and 23 (21%) had also low C3. Mean TCZ treatment period was 4.9 years (range, 1-14 years). All patients had normal complement levels at baseline. Leukopenia occurred in 18 (16.7%) patients, 14 of whom (77%) had low complement. Persistent leukopenia was observed in 8% and 5.3% of patients with normal C3 and C4 levels, respectively, as opposed to 47% and 42% of patients with low C3 or low C4, respectively. Low C3, C4 levels correlated with prolonged TCZ treatment retention time and effectiveness. There were no serious bacterial infections or new onset AID.Hypocomplementemia during TCZ treatment was accompanied by leukopenia that correlated with treatment duration. Hypocomplementemia was not associated with serious bacterial infections or new onset AID. Decreased complement levels were associated with treatment longevity. The role of monitoring complement level in predicting treatment response or assessing disease activity deserves further investigation.
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Affiliation(s)
- Amir Bieber
- Rheumatology Unit, Ha’Emek Medical Center, Afula, Israel
| | - Doron Markovits
- B Shine Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Kohava Toledano
- B Shine Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Yonit Tavor
- B Shine Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Reuven Mader
- Rheumatology Unit, Ha’Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Alexandra Balbir-Gurman
- B Shine Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Yolanda Braun-Moscovici
- B Shine Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Zhou M, Yuan F. Hypocomplementemia in Primary Sjogren's Syndrome: A Retrospective Study of 120 Treatment-Naive Chinese Patients. Int J Gen Med 2022; 15:359-366. [PMID: 35035231 PMCID: PMC8754462 DOI: 10.2147/ijgm.s346188] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/24/2021] [Indexed: 11/23/2022] Open
Abstract
Objective To determine the prevalence of hypocomplementemia in primary Sjogren’s syndrome (pSS) patients and compare the clinical characteristics of patients with and without hypocomplementemia. Methods A retrospective study was conducted in 120 treatment-naive Chinese patients that met the 2012 American College of Rheumatology Classification Criteria for pSS and were followed up for 3 to 24 months. Based on the complement results, patients were divided into four groups: only low C3, only low C4, both low C3 and C4 (double low), normal group. The data on patient demographics, clinical manifestations, laboratory results, disease activity and pharmacologic therapy were collected and compared among the four groups. Results The prevalence of only low C3, only low C4, both low C3 and C4 in pSS patients was 21.7%, 16.7%, and 10%, respectively. The mean age of the four groups was significantly different. Unlike rampant caries and parotitis, the prevalence of dry eyes and dry mouth differed among the four groups. The proportion of patients with anemia, leukocytopenia, lymphadenopathy, hematological involvement and fatigue was significantly higher in the double low group and lower in the normal complement group. The proportion of patients with increased serum IgG was higher in the only low C4 group than in the other groups. Logistic regression revealed that hypocomplementemia was an independent risk factor for lymphadenopathy and leukopenia. The double low group had a significant history of exposure to glucocorticoids and cyclophosphamide, compared with other groups. Conclusion Our study found that the clinical characteristics of pSS patients with hypocomplementemia differed from those without hypocomplementemia. Hypocomplementemia in pSS was associated with hematological involvement, hyper-IgG, lymphadenopathy, and fatigue, contributing to more significant exposure to glucocorticoid and cyclophosphamide.
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Affiliation(s)
- Meiju Zhou
- Department of Rheumatology and Immunology, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
| | - Fang Yuan
- Department of Rheumatology and Immunology, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
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Abstract
IgA vasculitis (IgAV, also known as Henoch-Schönlein purpura or HSP) is a vasculitis of small vessels involving multiple organs, particularly of the joints, gastrointestinal tract, skin, and kidneys. Growing laboratory evidence has shown that complement plays a key role in the pathogenesis of IgAV, although direct evidence of this association in patients is lacking. We report a child with IgAV associated with clinical features of hypertension, nephrotic range proteinuria, acute kidney injury, and low serum C3, with histopathologic findings on renal biopsy of membranoproliferative glomerulonephritis with C3 and IgA co-dominance, and extensive complement derangements. This case report suggests that complement modifies the pathogenesis of IgAV, and further investigation into complement-targeted therapy in cases of refractory IgAV may be beneficial.
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Affiliation(s)
- Melvin Chan
- Department of Pediatric Nephrology, Children's Hospital Colorado, Aurora, CO, United States
| | - Melisha Gayle Hanna
- Department of Pediatric Nephrology, Children's Hospital Colorado, Aurora, CO, United States
| | - Nicholas Willard
- Department of Pathology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Amy Treece
- Department of Pathology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Bradley Patton Dixon
- Department of Pediatric Nephrology, Children's Hospital Colorado, Aurora, CO, United States
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Toraman A, Soysal Gündüz Ö. Predictors of renal and patient outcomes in anti-neutrophil cytoplasmic antibody-associated vasculitis: Our single-center, tertiary care experience. Arch Rheumatol 2021; 36:445-457. [PMID: 34870177 PMCID: PMC8612491 DOI: 10.46497/archrheumatol.2021.8687] [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: 01/03/2021] [Accepted: 02/26/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives
This study aims to assess the different predictors of renal and patient prognosis in anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) patients with and without renal involvement. Patients and methods
A total of 79 patients (51 males, 28 females; mean age: 57.3±14.2 years; range, 18 to 71 years) with AAV between January 2006 and November 2019 were retrospectively analyzed. Demographic and laboratory data including the complement 3 (C3) serum levels and renal biopsy findings were extracted from the electronic and printed medical records of the hospital registry. Survival, renal survival, remission, and relapse outcomes were analyzed. Results
A total of 35% of the patients with renal involvement progressed to end-stage renal disease (ESRD). The dialysis requirement at the time of admission (hazard ratio [HR]: 21.95 [2.93-164.22]; p=0.003), estimated glomerular filtration rate (eGFR) (HR: 0.97 [0.94-0.99]; p=0.024) and Five-Factor Score (FFS) ≥2 at the time of diagnosis (HR: 3.59 [1.08-11.94]; p=0.037) were the predictors of ESRD. The five-year patient survival rate was 87.1%. The only predictor of mortality was age (HR: 1.07 [1.01-1.14]; p=0.024). The patients with hypocomplementemia (22%) had a lower remission rate (p=0.049), FFS ≥2 at the time of diagnosis (p=0.026), and higher levels of hematuria (p=0.004) and proteinuria (p=0.037). The FFS ≥2 at the time of diagnosis was an independent predictor of relapse (HR: 8.9 [1.02-77.36]; p=0.047). Conclusion
Our study suggests that the baseline renal function and FFS ≥2 at the time of diagnosis are the major prognostic factors for progression to ESRD in AAV patients. In addition, AAV patients with hypocomplementemia may have a lower remission rate.
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Affiliation(s)
- Aysun Toraman
- Department of Internal Medicine, Division of Nephrology, Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Özgül Soysal Gündüz
- Department of Internal Medicine, Division of Rheumatology, Celal Bayar University, Faculty of Medicine, Manisa, Turkey
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Rehan A. Kidney Injury in a Patient with Hypocomplementemia and Diffuse Lymphadenopathy. Kidney360 2021; 2:1684-1685. [PMID: 35372982 PMCID: PMC8785795 DOI: 10.34067/kid.0003892021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Anam Rehan
- Yale School of Medicine, New Haven, Connecticut
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13
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Bhattad PB, Joseph DL, Peterson E. IgG4-Related Disease Manifesting as Hypocomplementemic Tubulointerstitial Nephritis: A Rare Case Report and Literature Review. J Investig Med High Impact Case Rep 2021; 8:2324709620952213. [PMID: 32830581 PMCID: PMC7448130 DOI: 10.1177/2324709620952213] [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: 11/29/2022] Open
Abstract
Immunoglobulin G4–related disease (IgG4-RD) is a chronic fibrosing inflammatory systemic disorder that has been recognized relatively recently in the medical literature. Little is known about the exact disease pathogenesis and epidemiology. IgG4-RD may be asymptomatic or may have minimal symptoms or involve multiple organs with overt symptoms. The different phenotypes of IgG4-RD can lead to delayed or incorrect diagnosis. We report the case of a 66-year-old male with coal worker’s pneumoconiosis who presented with progressive kidney disease and was diagnosed with tubulointerstitial nephritis due to IgG4-RD. The patient was noted to have progressive kidney disease, skin involvement, worsening interstitial lung disease, complete vision loss in the left eye, and retroperitoneal fibrosis. Serologic workup revealed elevated inflammatory markers, IgG4 and IgG1 levels, and hypocomplementemia. A tissue biopsy helped us establish a definitive diagnosis of IgG4-RD and initiate treatment with glucocorticoids to prevent further progression of kidney disease and other end-organ damage.
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Affiliation(s)
| | - David L Joseph
- James H. Quillen Veterans Affairs Medical Center, Johnson City, TN, USA
| | - Eric Peterson
- James H. Quillen Veterans Affairs Medical Center, Johnson City, TN, USA
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Pan YY, Zhou SC, Wang YJ, Zhu TT, Peng D, Guan HX. IgG4-Related Disease: A Retrospective Chinese Study of Features and Treatment Response of 98 Patients Including 4 Rare Cases. Curr Med Sci 2021; 41:390-397. [PMID: 33877558 DOI: 10.1007/s11596-021-2359-5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 09/29/2020] [Indexed: 11/29/2022]
Abstract
The features and treatment of 98 Chinese patients with immunoglobulin G4 (IgG4)-related disease (IgG4-RD) referred to a single tertiary referring centre were reviewed. Patients diagnosed with IgG4-RD according to the comprehensive diagnostic criteria (CDC) were included in the retrospective study from May 2012 to March 2019. We collected data on clinical, laboratory, imaging, histological features and treatment. Totally, 98 patients with IgG4-RD were enrolled. The common clinical manifestations included abdominal pain, salivary gland swelling and lymphadenopathy. 51% of the patients had multiple organs involvement. Lymph nodes, pancreas and salivary glands were most commonly involved. Four rare sites including ulna, cerebellum, scalp, and mammary gland were found. The serum IgG4 level was increased by 85.7%. The serum IgG4 level was positively correlated with the number of involved organs, IgG and IgG4/IgG. Low C3 and C4 levels were observed in 37.5% and 12.2% patients respectively, and all patients with kidney involvement had hypocomplementemia. A total of 54 patients underwent tissue biopsies, and 55.6%, 31.5% and 11.1% cases were diagnosed as definite, probable and possible IgG4-RD, respectively. Eighty-eight patients received glucocorticoids (GCs) therapy. Five patients underwent radical surgery to remove the lesion. 73% of them presented a complete or partial remission. IgG4-RD is a systemic fibroinflammatory disease with involvement of multiple organs throughout the body including some rare sites. Most IgG4-RD patients had increased serum IgG4 levels and patients with kidney involvement showed hypocomplementemia. GCs therapy is effective. More research is needed to provide a more reliable basis for the diagnosis and treatment of patients.
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Affiliation(s)
- Yue-Ying Pan
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shu-Chang Zhou
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yu-Jin Wang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ting-Ting Zhu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Dan Peng
- Department of Nuclear Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Han-Xiong Guan
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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15
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Abstract
Cerebral rheumatoid vasculitis (CRV) is a rare, fatal, and diagnostically challenging disorder. We herein report an 81-year-old woman with a 4-year history of rheumatoid arthritis who presented with a fever, progressive disturbance of consciousness, high level of rheumatoid factor, and hypocomplementemia. The enhancement of the perforating branches in the left middle cerebral artery led us to suspect CRV. A brain biopsy could not be performed. After we intensified steroid therapy, the size of the cerebral lesions temporarily decreased. However, recurrence in the left frontal lobe occurred one month later, and the patient subsequently died. Early intensive treatments may be needed for CRV.
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Affiliation(s)
| | | | - Yasuyuki Hara
- Department of Neurology, Kumamoto Rosai Hospital, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
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16
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Kobayashi S, Kakeshita K, Imamura T, Fujioka H, Yamazaki H, Koike T, Kinugawa K. Clinical Implications of Steroid Therapy for Crescentic Glomerulonephritis and Gemella morbillorum-associated Infective Endocarditis. Intern Med 2021; 60:299-303. [PMID: 32921686 PMCID: PMC7872803 DOI: 10.2169/internalmedicine.5319-20] [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: 01/10/2023] Open
Abstract
A 54-year-old man was admitted to our institute with a diagnosis of infective endocarditis (IE) with vegetation on the mitral valve and severe regurgitation due to Gemella morbillorum infection together with renal dysfunction, which was eventually diagnosed as infection-related pauci-immune necrotizing crescentic glomerulonephritis. Given the refractoriness to antibiotics, the persistent activity of nephritis, and repeated cerebral hemorrhaging, we prioritized steroid therapy over early surgical mitral valve replacement. Following steroid therapy, the glomerulonephritis completely improved. Although the administration of steroid therapy in the active phase of IE remains controversial, it might be indicated if comorbid glomerulonephritis is critical.
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Affiliation(s)
- Shiori Kobayashi
- The Second Department of Internal Medicine, University of Toyama, Japan
| | - Kota Kakeshita
- The Second Department of Internal Medicine, University of Toyama, Japan
| | - Teruhiko Imamura
- The Second Department of Internal Medicine, University of Toyama, Japan
| | - Hayato Fujioka
- The Second Department of Internal Medicine, University of Toyama, Japan
| | - Hidenori Yamazaki
- The Second Department of Internal Medicine, University of Toyama, Japan
| | - Tsutomu Koike
- The Second Department of Internal Medicine, University of Toyama, Japan
| | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, Japan
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Ueda A, Chigusa Y, Mogami H, Kawasaki K, Horie A, Mandai M, Kondoh E. Predictive factors for flares of established stable systemic lupus erythematosus without anti-phospholipid antibodies during pregnancy. J Matern Fetal Neonatal Med 2020; 35:3909-3914. [PMID: 33143489 DOI: 10.1080/14767058.2020.1843626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE To identify predictors of systemic lupus erythematosus (SLE) flares during pregnancy in patients previously considered to be at low risk. MATERIALS AND METHODS The retrospective cohort study included 54 singleton pregnancies, managed between 2005 and 2019, involving maternal diagnosed SLE at a low disease activity (SLE Disease Activity Index ≤4) for ≥12 months before conception and without anti-phospholipid antibodies. Pregnancy outcomes were compared between patients who had SLE exacerbations during pregnancy (flare group, n = 21) and patients that did not have a flare (non-flare group, n = 33). RESULTS The flare group had shorter gestational durations (p = .01), lower birth weights (p = .02), and a higher risk of emergent cesarean section (p = .002) compared with the non-flare group. The flare group demonstrated higher doses of prednisone (p = .04) at the time of conception as well as an increased rate of low 50% hemolytic complement (CH50) activity (p = .03) in the first trimester compared to the non-flare group. A decision tree drawn using a prednisone dose ≥10.5 mg/day and a low CH50 predicted SLE flares with a net accuracy of 78%. CONCLUSIONS A prednisone dose ≥10.5 mg daily and CH50 hypocomplementemia in early pregnancy are useful in the early detection of patients at a high risk of SLE exacerbation.
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Affiliation(s)
- Akihiko Ueda
- Department of Gynecology and Obstetrics, Kyoto University, Kyoto, Japan
| | | | - Haruta Mogami
- Department of Gynecology and Obstetrics, Kyoto University, Kyoto, Japan
| | - Kaoru Kawasaki
- Department of Gynecology and Obstetrics, Kyoto University, Kyoto, Japan
| | - Akihito Horie
- Department of Gynecology and Obstetrics, Kyoto University, Kyoto, Japan
| | - Masaki Mandai
- Department of Gynecology and Obstetrics, Kyoto University, Kyoto, Japan
| | - Eiji Kondoh
- Department of Gynecology and Obstetrics, Kyoto University, Kyoto, Japan
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18
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Pan BH, Kong YL, Wang L, Zhu HY, Li XT, Liang JH, Xia Y, Wu JZ, Fan L, Li JY, Xu W. The prognostic roles of hypogammaglobulinemia and hypocomplementemia in newly diagnosed diffuse large B-cell lymphoma. Leuk Lymphoma 2020; 62:291-299. [PMID: 33063579 DOI: 10.1080/10428194.2020.1832673] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most frequent type of lymphoma. Our retrospective study included 553 newly diagnosed DLBCL patients from May 2009 to October 2019. The relationships between hypogammaglobulinemia, hypocomplementemia and progression-free survival (PFS) and overall survival (OS) were assessed. In our center, 19.0% of patients had hypogammaglobulinemia, and 7.7% had hypocomplementemia at diagnosis. Immunoglobulin and complement deficiencies were associated with advanced disease and displayed inferior PFS and OS. Then, we designed a new immunization cumulative prognostic score (ICPS) model to comprehensively clarify the effect of these two variables on prognosis. Multivariate analysis showed that ICPS was an independent prognostic indicator for inferior clinical outcomes (PFS: p = 0.007, OS: p = 0.003). Furthermore, the predictive effect of ICPS combined with the International Prognostic Index (IPI) was superior to that of IPI alone (PFS: p = 0.016, OS: p = 0.037). In conclusion, hypogammaglobulinemia and hypocomplementemia could be regarded as adverse prognostic indicators in DLBCL.
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Affiliation(s)
- Bi-Hui Pan
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Yi-Lin Kong
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Li Wang
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Hua-Yuan Zhu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Xiao-Tong Li
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Jin-Hua Liang
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Yi Xia
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Jia-Zhu Wu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Lei Fan
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Jian-Yong Li
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Wei Xu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
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19
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Fan HH, Lin IC, Chen JE, Lee WH, Fang SB. Anorexia nervosa manifesting as massive ascites, hypercholesterolemia, and sequential binge eating in an 11-year-old girl: A case report. Medicine (Baltimore) 2020; 99:e21739. [PMID: 32871893 PMCID: PMC7458216 DOI: 10.1097/md.0000000000021739] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Anorexia nervosa (AN) is a serious eating disorder associated with a distorted body image. Hypercholesterolemia has been found in patients with AN but the mechanism of hyperlipidemia in AN remains little known. Ascites in patients with AN has been attributed to hypoalbuminemia and liver diseases, but massive ascites without the aforementioned etiologies has never been reported in AN. PATIENT CONCERNS An 11-year-old girl was admitted for exclusion of organic underlying diseases due to severe body weight loss (18% within 3 weeks), poor appetite, and hypercholesterolemia (274 mg/dL). She complained of heartburn sensation, nausea, vomiting, constipation, and postprandial dull abdominal pain with fullness. DIAGNOSES The patient's condition met with all 3 of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for diagnosing AN. On admission, her total cholesterol level was 337 mg/dL and hypocomplementemia (C3 55.5 mg/dL) was also found. Abdominal sonography and computed tomography scans showed massive ascites. However, neither proteinuria nor hypoalbuminemia was found. Upper gastroduodenal endoscopy showed chronic superficial gastritis and colonoscopy revealed negative findings. Ascites obtained by paracentesis demonstrated a transudate without bacterial infection, tuberculosis, or pancreatitis. Exploratory laparoscopy showed nonpurulent ascites. However, biopsies from the small intestine, mesentery, and liver showed chronic inflammation and fibrosis. INTERVENTIONS The intensive nutritional therapy by increasing total energy intake stepwise with a combination of high-energy formula and her favorite foods. OUTCOMES Her hypercholesterolemia, hypocomplementemia, and massive ascites resolved after her weight was restored. She developed binge eating with continuous weight gain after discharge. Her weight significantly increased to an obese level (body mass index [BMI] 25.9 kg/m) after loss to follow-up for 4 years until she returned to our emergency room due to suicide attempt. CONCLUSION Diagnostic crossover between subtypes in anorexia nervosa might be a potential risk factor for illness severity and poor prognosis. AN can manifest as massive ascites with normal albumin concentrations that could possibly be due to chronic inflammation of the intestinal serosa, mesentery, and peritoneal surface of the liver.
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Affiliation(s)
- Hung-Hao Fan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics
- Department of Pediatrics, School of Medicine, College of Medicine
| | | | - Jing-Er Chen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics
| | | | - Shiuh-Bin Fang
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics
- Department of Pediatrics, School of Medicine, College of Medicine
- Master Program for Clinical Pharmacogenomics and Pharmacoproteomics, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
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20
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Fujii T, Iwabuchi Y, Moriyama T, Uchida K, Nitta K. A case of Lemierre syndrome combined with a suspected systemic lupus erythematosus flare. SAGE Open Med Case Rep 2019; 7:2050313X19871782. [PMID: 31489196 PMCID: PMC6709436 DOI: 10.1177/2050313x19871782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 04/12/2018] [Accepted: 08/01/2019] [Indexed: 11/16/2022] Open
Abstract
Lemierre syndrome develops in healthy young patients as a result of bacteremia
after oral cavity infection. It causes thrombophlebitis in the internal jugular
vein. Infection can easily occur during immunosuppressive treatment in patients
with systemic lupus erythematosus and become severe. We present a case of
Lemierre syndrome in a patient with systemic lupus erythematosus. A 56-year-old
woman presented with fever, left lower toothache, and skin symptoms from the
left neck to the anterior chest. Clinical presentation and laboratory
investigations revealed Lemierre syndrome. The inflammation and thrombus
disappeared with antibiotic and anticoagulant therapies. However, transient
hypocomplementemia and elevated antinuclear antibody levels were observed during
treatment; therefore, a concomitant systemic lupus erythematosus flare was
considered. In systemic lupus erythematosus patients with Lemierre syndrome,
complement and antinuclear antibody levels are modified, so other indicators
should be precisely evaluated, such as levels of urinary protein, sediment,
serum creatinine and anti-dsDNA antibody, and systemic lupus erythematosus
disease activity index.
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Affiliation(s)
- Teruhiro Fujii
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Yuko Iwabuchi
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Takahito Moriyama
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Keiko Uchida
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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Abstract
A diagnosis of hereditary angioedema is usually made with recurrent episodes of swelling of the subcutaneous tissue with a family history. We herein report a case in which recurrent acute abdomen was the main manifestation of hereditary angioedema. A 45-year-old womon presented with a 10-year history of recurrent severe abdominal pain. Abdominal computed tomography revealed remarkable submucosal edema of the ileum. A blood examination revealed grossly reduced complement C4 and CH50 with deficiency of C1-inhibitor. Genetic testing revealed a heterozygous nonsense mutation of the SERPING1 gene, and a diagnosis of hereditary angioedema was made. Hereditary angioedema should be listed as a differential diagnosis of recurrent acute abdomen.
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Affiliation(s)
- Keiichi Iwanami
- Department of Rheumatology, Tokyo Bay Urayasu/Ichikawa Medical Center, Japan
| | - Tsubasa Okano
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Japan
| | - Osamu Ohara
- Department of Genome Research and Development, Kazusa DNA Research Institute, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Japan
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22
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Li J, Umakanathan M, P'ng CH, Varikatt W, Kwok F, Lin MW, Vucak-Dzumhur M. Cryoglobulinemic Glomerulonephritis Associated With Nodal and Renal Infiltration by T-Cell Lymphoma of T-Follicular Helper Phenotype: A Case Report. Am J Kidney Dis 2018; 72:606-611. [PMID: 29784613 DOI: 10.1053/j.ajkd.2018.03.024] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 03/15/2018] [Indexed: 01/24/2023]
Abstract
We present a unique case of cryoglobulinemic glomerulonephritis associated with nodal and renal infiltration by T-cell lymphoma of T-follicular helper phenotype. The patient presented with transient neurologic symptoms, severe nephritic syndrome with nephrotic-range proteinuria, and acute kidney injury. He had elevated double-stranded DNA levels, low complement levels, detectable cryoglobulin, and detectable immunoglobulin M (IgM) paraprotein. The kidney biopsy showed cryoglobulinemic glomerulonephritis with a membranoproliferative pattern and diffuse interstitial infiltrates on light microscopy; IgM, C3 but weak IgG, C1q, and negative C4d staining on immunofluorescence; and deposits with organized substructures on electron microscopy. Positron emission tomography showed diffuse uptake in bilaterally enlarged kidneys and a localized group of lymph nodes. Subsequent lymph node biopsy revealed Epstein-Barr virus-negative nodal T-cell lymphoma, which was also proven in renal tissue. The association between T-cell lymphoma, autoantibodies, and cryoglobulinemia may represent a paraneoplastic phenomenon. His renal prognosis has been excellent, but overall prognosis and survival is dictated by the clinical course of T-cell lymphoma.
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Affiliation(s)
- Jennifer Li
- Department of Renal Medicine, Westmead Hospital, Sydney, NSW, Australia.
| | | | - Chow Heok P'ng
- Department of Pathology, Westmead Hospital, Sydney, NSW, Australia
| | - Winny Varikatt
- Department of Pathology, Westmead Hospital, Sydney, NSW, Australia
| | - Fiona Kwok
- Department of Haematology, Westmead Hospital, Sydney, NSW, Australia
| | - Ming-Wei Lin
- Department of Immunology, Westmead Hospital, Sydney, NSW, Australia
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23
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Fukui S, Iwamoto N, Umeda M, Nishino A, Nakashima Y, Koga T, Kawashiri SY, Ichinose K, Hirai Y, Tamai M, Nakamura H, Origuchi T, Sato S, Kawakami A. Antineutrophilic cytoplasmic antibody-associated vasculitis with hypocomplementemia has a higher incidence of serious organ damage and a poor prognosis. Medicine (Baltimore) 2016; 95:e4871. [PMID: 27631255 PMCID: PMC5402598 DOI: 10.1097/md.0000000000004871] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [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: 12/03/2022] Open
Abstract
A relationship between antineutrophilic cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and complement has been shown, and complement has an important role in the pathogenesis of AAV. The clinical characteristics of AAV with hypocomplementemia still remain unclear.We conducted an observational study of 81 patients with AAV (median onset age 71 years; 58% female). Using medical records, we analyzed the patients' baseline variables, laboratory data, clinical symptoms, and therapeutic outcomes after treatments including episodes of relapses, initiation of dialysis, and death. We defined hypocomplementemia as the state in which at least one of the following was lower than the lower limit of the normal range: complement 3 (C3), complement 4 (C4), and total complement activity (CH50).Sixteen patients (20%) had hypocomplementemia at their diagnosis of AAV. Compared to the AAV patients without hypocomplementemia (n = 65), those with hypocomplementemia had significantly higher rates of the occurrence of skin lesions (8 [50%] vs. 8 [12%], P = 0.002), diffuse alveolar hemorrhage (DAH) (6 [38%] vs. 5 [8%], P = 0.006), and thrombotic microangiopathy (TMA) (3 [19%] vs. 0 [0%], P = 0.007). The AAV patients with hypocomplementemia had significantly lower platelet levels (16.5 × 10 vs. 24.9 × 10 cells/μL, P = 0.023) compared to those without hypocomplementemia. More positive immune complex deposits in renal biopsy specimens were seen in the AAV patients with hypocomplementemia than in those without hypocomplementemia (4 [80%] vs. 2 [18%], P = 0.036). Assessed by a log-rank test, hypocomplementemia at disease onset was significantly associated with death (P = 0.033).Hypocomplementemia in AAV at the disease onset was a risk factor for the serious organ damage, and a life prognostic factor. It is thus very important to pay attention to the levels of complement at the diagnosis of AAV.
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Affiliation(s)
| | | | | | | | | | | | - Shin-ya Kawashiri
- Department of Immunology and Rheumatology
- Department of Public Health
| | | | | | - Mami Tamai
- Department of Immunology and Rheumatology
| | | | - Tomoki Origuchi
- Department of Immunology and Rheumatology
- Department of Rehabilitation Sciences, Unit of Translational Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Shuntaro Sato
- Nagasaki University Hospital Clinical Research Center, Nagasaki, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology
- Correspondence: Dr. Atsushi Kawakami, Unit of Translational Medicine, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, 1–7–1 Sakamoto, Nagasaki 852–8501, Japan (e-mail: )
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24
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Raoufi M, Laine M, Amrani HN, Souhi H, Janah H, Elouazzani H, Rhorfi IA, Abid A. [Severe pulmonary involvement in hypocomplementemic urticarial vasculitis (HUV)]. Pan Afr Med J 2016; 24:285. [PMID: 28154640 PMCID: PMC5267844 DOI: 10.11604/pamj.2016.24.285.8168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 06/19/2016] [Indexed: 11/11/2022] Open
Abstract
Pulmonary involvement in hypocomplementemic urticarial vasculitis (HUV) or Mac Duffie syndrome is extremely rare with a poor prognosis. We report the case of a 55-year-old female patient treated for HUV over a period of 20 years. The diagnosis was confirmed on the basis of urticarial lesions, ocular inflammation, positive C1q-p test by immunodiffusion, with low rate of C1q. The patient was treated with cycles of cyclophosphamide, corticoids and rituximab as she developed class III dyspnea (NYHA classification ). The clinico-radiological and functional assessment showed thoracic distension and severe obstructive pulmonary disease which found no significant improvement with systemic treatment Aerosol therapy was started and the patient had a marked clinical improvement. Pulmonary involvement in Mac Duffie hypocomplementemic urticarial vasculitis worsens the patient short-term vital prognosis. The knowledge of the different types of pulmonary involvement opens new therapeutic prospects.
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Affiliation(s)
- Mohammed Raoufi
- Service de Pneumologie, Hôpital Militaire Mohamed V, Rabat, Maroc
| | - Mustapha Laine
- Service de Pneumologie, Hôpital Militaire Mohamed V, Rabat, Maroc
| | | | - Hicham Souhi
- Service de Pneumologie, Hôpital Militaire Mohamed V, Rabat, Maroc
| | - Hicham Janah
- Service de Pneumologie, Hôpital Militaire Mohamed V, Rabat, Maroc
| | | | | | - Ahmed Abid
- Service de Pneumologie, Hôpital Militaire Mohamed V, Rabat, Maroc
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Xu JM, Wang R. Diffuse mesangial and endocapillary cell proliferative glomerulonephritis with persistent hypocomplementemia in a child. Int J Clin Exp Med 2015; 8:16834-16837. [PMID: 26629229 PMCID: PMC4659117] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 08/06/2015] [Indexed: 06/05/2023]
Abstract
A 15-year-old boy was admitted to People's Hospital of Dong E with anasarca. The laboratory findings revealed proteinuria, hematuria, hypocomplementemia. Renal biopsy specimen revealed diffuse mesangial and endocapillary cell proliferative glomerulonephritis on light microscopic (LM) examination. On immunofluorescence (IF) examination, deposition of IgG, IgA, C3, C1q and F to capillary wall and subendothelial were observed. By means of electron microscopy (EM), subendothelial electron-dense deposits and segmental fusion of epithelial cell foot process were recognized. He was treated by only some supportive drugs, no ACEI/ARB, without glucocorticoids and immunosuppressive agents. About one month later, complete remission of proteinuria occurred. During next 62-weeks follow up, urinary analysis always showed microscopic hematuria. However, it is interesting to note that the serum complement C3 and C4 levels remained persistently low.
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Affiliation(s)
- Jun-Mei Xu
- Shandong UniversityJinan 250100, P. R. China
- Department of Nephrology, People’s Hospital of Dong E countyLiaocheng 252200, People’s P. R. China
| | - Rong Wang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong UniversityJinan 250021, P. R. China
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Higuchi Y, Shimizu J, Hatanaka M, Kitano E, Kitamura H, Takada H, Ishimura M, Hara T, Ohara O, Asagoe K, Kubo T. The identification of a novel splicing mutation in C1qB in a Japanese family with C1q deficiency: a case report. Pediatr Rheumatol Online J 2013; 11:41. [PMID: 24160257 PMCID: PMC3874733 DOI: 10.1186/1546-0096-11-41] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 10/25/2013] [Indexed: 01/20/2023] Open
Abstract
C1q deficiency is a rare disease that is associated with a high probability of developing systemic lupus erythematosus. We report a 4-year-old Japanese girl who presented with fever, facial erythema, joint pain, and oral ulceration. Complement deficiencies were suspected because of her persistent hypocomplementemia and normal levels of the complement proteins C3 and C4. We identified a novel homozygous splicing mutation in the C1qB gene, c.187 + 1G > T, which is the first mutation to be confirmed in a Japanese individual. Because treatment with steroids and immunosuppressive drugs was not effective, we commenced use of fresh frozen plasma to provide C1q supplements. Currently, the patient remains almost asymptomatic, and we are attempting to control the drug dosage and administration intervals of fresh frozen plasma.
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Affiliation(s)
- Yousuke Higuchi
- Department of Pediatrics, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
| | - Junya Shimizu
- Department of Pediatrics, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan.
| | - Michiyo Hatanaka
- Department of Medical Technology Faculty of Health Sciences, Kobe Tokiwa University, 2-6-2 Ohtanicho, Nagata-ku, Kobe 653-0838, Japan
| | - Etsuko Kitano
- Department of Medical Technology Faculty of Health Sciences, Kobe Tokiwa University, 2-6-2 Ohtanicho, Nagata-ku, Kobe 653-0838, Japan
| | - Hajime Kitamura
- Department of Medical Technology Faculty of Health Sciences, Kobe Tokiwa University, 2-6-2 Ohtanicho, Nagata-ku, Kobe 653-0838, Japan
| | - Hidetoshi Takada
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higasi-ku, Fukuoka 812-8582, Japan
| | - Masataka Ishimura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higasi-ku, Fukuoka 812-8582, Japan
| | - Toshiro Hara
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higasi-ku, Fukuoka 812-8582, Japan
| | - Osamu Ohara
- Department of Human Genome Technology, Kazusa DNA Research Institute, 2-6-7 Kazusakamatari, Chiba 292-0818, Japan
| | - Kenji Asagoe
- Department of Dermatology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
| | - Toshihide Kubo
- Department of Pediatrics, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
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Oshio M, Fujii T, Kusaura T, Nagahama K. Relapsing proliferative glomerulonephritis with monoclonal IgG deposits showing circumferential crescentic glomerulonephritis. Clin Kidney J 2013; 6:635-8. [PMID: 26069833 PMCID: PMC4438369 DOI: 10.1093/ckj/sft121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 08/22/2013] [Accepted: 09/10/2013] [Indexed: 11/13/2022] Open
Abstract
Several types of glomerulonephritis associated with dysproteinemia, such as AL-amyloidosis, light- and heavy-chain deposition disease, and type 1 cryoglobulinemic glomerulopathy, demonstrate monoclonal immunoglobulin deposition. Progressive glomerulonephritis with monoclonal IgG deposits (PGNMID) is also known to feature monoclonal glomerular deposits, but most of these cases occur without underlying disease. We here report a case of recurrent PGNMID that developed as diffuse cellular crescentic glomerulonephritis 8 years after an initial diagnosis of membranoproliferative glomerulonephritis (MPGN). Determination of the monoclonality of the deposited immunoglobulin is vital to make the correct diagnosis and enable an early administration of aggressive immunosuppressive therapy.
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Affiliation(s)
- Mai Oshio
- Nephrology Unit , Hiratsuka Kyosai Hospital , Hiratsuka , Japan
| | - Takuma Fujii
- Nephrology Unit , Hiratsuka Kyosai Hospital , Hiratsuka , Japan
| | - Takashi Kusaura
- Nephrology Unit , Hiratsuka Kyosai Hospital , Hiratsuka , Japan
| | - Kiyotaka Nagahama
- Department of Pathology , Yokohama City University School of Medicine , Yokohama , Japan
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Grotz W, Baba HA, Becker JU, Baumgärtel MW. Hypocomplementemic urticarial vasculitis syndrome: an interdisciplinary challenge. Dtsch Arztebl Int 2009; 106:756-63. [PMID: 20019864 DOI: 10.3238/arztebl.2009.0756] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Accepted: 04/21/2009] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chronic urticaria often points the way to the diagnosis of a systemic disease, particularly when urticarial vasculitis can be demonstrated. Hypocomplementemic urticarial vasculitis syndrome (HUVS) is considered to be an independent immunological disease. METHOD Selective literature review and consideration of the author's own clinical experience. RESULTS AND CONCLUSIONS The main manifestation of HUVS is chronic urticarial vasculitis with complement deficiency and the demonstration of C1q antibody in the serum. Multiple other organs are involved, sometimes severely. The diagnosis is confirmed by skin biopsy, which reveals leukocytoclastic vasculitis as a pathogenetic correlate of this systemic disease. Although HUVS is relatively rare, the medical specialists that might encounter it-ophthalmologists, rheumatologists, nephrologists, dermatologists, general practitioners, and pediatricians-should include it in their differential diagnoses whenever appropriate. Awareness of HUVS and rational diagnostic evaluation will lessen the chance of it being misdiagnosed as another type of systemic immunological disease and will reduce superfluous diagnostic testing in patients suffering from it.
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Fujita T, Satomura A, Hidaka M, Ohsawa I, Endo M, Ohi H. Inhibitory effect of free sialic acid on complement activation and its significance in hypocomplementemic glomerulonephritis. J Clin Lab Anal 1999; 13:173-9. [PMID: 10414597 PMCID: PMC6807753] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023] Open
Abstract
The role of free sialic acid on complement activation was investigated. The serum levels of free sialic acid and total sialic acid were measured by previously described methods in 16 patients with acute post-infectious glomerulonephritis (AGN), 27 patients with systemic lupus erythematosus (SLE), 15 patients with persistent hypocomplementemic membranoproliferative glomerulonephritis (MPGN), and 13 healthy controls. A statistical study demonstrated an increased level of free sialic acid in patients with AGN and SLE in which the hypocomplementemia improved throughout the course and a decreased level of free sialic acid in patients with MPGN and SLE in which hypocomplementemia continued throughout the course. The levels of total sialic acid were significantly increased in patients with AGN and SLE and were significantly decreased in patients with MPGN. There was no correlation between the levels of free sialic acid and total sialic acid in patients with AGN, in whom the levels of both total and free sialic acids were increased. To examine the effect of free sialic acid on the complement cascade, lipopolysaccharide (LPS) was incubated with normal human serum (NHS) in the various concentrations of N-acetyl neuraminic acid (NANA), a member of the sialic acid group. The incubation mixtures were examined by enzyme immunoassay using monoclonal anti-iC3b antibody or anti-Bb antibody. Native C3 or Factor B in NHS broke down less following the addition of NANA. To elucidate the role of NANA on the hemolytic function of C3, a rabbit erythrocyte (Ra E) hemolytic assay was carried out. Ra E lysed completely in the presence of R3 with native C3. However, hemolysis occurred to a lesser degree in C3-depleted serum (R3) or R3 with NANA-treated C3. To investigate the influence of NANA on complement components, the levels of complement components were measured in the incubation mixture with various doses of NANA and NHS. The levels of C3 and C5 were significantly decreased after the addition of NANA, even though the levels of Factor H and Factor I were not markedly changed. These data indicate that NANA exerts an influence on the complement components even though it has no effect on the regulatory proteins of complement. Our in vitro findings, together with the in vivo data, suggest that free sialic acid might have an inhibitory effect on the activation of C3 and the following complement cascade, and might also have been responsible for the improvement of hypocomplementemia.
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Affiliation(s)
- T Fujita
- Department of Internal Medicine II, Nihon University School of Medicine, Tokyo, Japan.
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