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He X, You R, Shi Y, Zeng Z, Tang B, Yu J, Xiao Y, Xiao R. Pyroptosis: the potential eye of the storm in adult-onset Still's disease. Inflammopharmacology 2023; 31:2269-2282. [PMID: 37429997 DOI: 10.1007/s10787-023-01275-0] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/02/2023] [Indexed: 07/12/2023]
Abstract
Pyroptosis, a form of programmed cell death with a high pro-inflammatory effect, causes cell lysis and leads to the secretion of countless interleukin-1β (IL-1β) and IL-18 cytokines, resulting in a subsequent extreme inflammatory response through the caspase-1-dependent pathway or caspase-1-independent pathway. Adult-onset Still's disease (AOSD) is a systemic inflammatory disease with extensive disease manifestations and severe complications such as macrophage activation syndrome, which is characterized by high-grade inflammation and cytokine storms regulated by IL-1β and IL-18. To date, the pathogenesis of AOSD is unclear, and the available therapy is unsatisfactory. As such, AOSD is still a challenging disease. In addition, the high inflammatory states and the increased expression of multiple pyroptosis markers in AOSD indicate that pyroptosis plays an important role in the pathogenesis of AOSD. Accordingly, this review summarizes the molecular mechanisms of pyroptosis and describes the potential role of pyroptosis in AOSD, the therapeutic practicalities of pyroptosis target drugs in AOSD, and the therapeutic blueprint of other pyroptosis target drugs.
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Affiliation(s)
- Xinglan He
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Medical Epigenetics, Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ruixuan You
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Medical Epigenetics, Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yaqian Shi
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Medical Epigenetics, Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhuotong Zeng
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Medical Epigenetics, Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Bingsi Tang
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Medical Epigenetics, Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jiangfan Yu
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Medical Epigenetics, Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yangfan Xiao
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China.
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, China.
| | - Rong Xiao
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
- Hunan Key Laboratory of Medical Epigenetics, Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
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Tsang DA, Hui L, Cheo FF, Pang SM. Neutrophilic urticarial dermatosis preceding adult-onset Still's disease. Dermatol Online J 2023; 29. [PMID: 37921815 DOI: 10.5070/d329461904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 11/04/2023] Open
Abstract
Neutrophilic urticarial dermatosis is a distinct entity strongly associated with underlying autoinflammatory disease. The pathogenesis of this condition has been considered to center around interleukin-1. We report a young woman with neutrophilic urticarial dermatosis who presented with a recurrent urticarial rash for two years prior to the onset of other systemic features including persistent fevers, sore throat, leukocytosis, elevated ferritin, and splenomegaly. She was ultimately diagnosed with adult-onset Still disease and responded well to treatment with systemic corticosteroids. Although neutrophilic urticarial dermatosis is known to occur in the setting of systemic symptoms and disease, its occurrence preceding the onset of systemic inflammation is less well-described in current literature.
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Affiliation(s)
- Denise Ann Tsang
- Department of Dermatology, Singapore General Hospital, Singapore
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Fujita Y, Yago T, Asano T, Matsumoto H, Matsuoka N, Temmoku J, Sato S, Yashiro-Furuya M, Suzuki E, Watanabe H, Kawakami A, Migita K. Clinical relevance for circulating cold-inducible RNA-binding protein (CIRP) in patients with adult-onset Still's disease. PLoS One 2021; 16:e0255493. [PMID: 34351954 PMCID: PMC8341607 DOI: 10.1371/journal.pone.0255493] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 07/17/2021] [Indexed: 11/18/2022] Open
Abstract
Background Adult-onset Still’s disease (AOSD) is a systemic autoinflammatory disease in which danger-associated molecular patterns (DAMPs)-mediated inflammasome activation seems to be involved in the disease pathogenesis. Cold-inducible RNA-binding protein (CIRP) belongs to a family of cold-shock proteins that respond to cellular stress and has been identified as a DAMP that triggers the inflammatory response. The aim of this study is to investigate the clinical significance of serum CIRP levels in AOSD. Methods Serum samples were obtained from 44 patients with active AOSD or 50 patients with rheumatoid arthritis (RA), 20 patients with systemic lupus erythematosus (SLE), and 15 healthy control patients (HCs). Serum levels of CIRP and IL-18 were determined using enzyme-linked immunosorbent assay. Results were compared among AOSD patients, RA patients, SLE patients and HCs. Results were also analyzed according to the clinical features of AOSD. Results Serum CIRP levels were significantly higher in AOSD patients compared with RA patients (median: 9.6 ng/mL, IQR [5.7–14.4] versus 3.2 ng/mL, IQR [1.9–3.8]; p < 0.001) and with HCs (2.8 ng/mL, [IQR; 1.4–4.9], p < 0.001). There was a significant positive correlation between serum CIRP levels and AOSD disease activity score (Pouchot’s score r = 0.45, p = 0.003) as well as between AOSD-specific biomarkers ferritin and IL-18. However, there was no significant difference in the serum CIRP levels among AOSD patients with three different disease phenotypes. Conclusions These results suggest that CIRP may play a significant role in the pathophysiology of AOSD and could be a potential biomarker for monitoring the disease activity of AOSD.
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Affiliation(s)
- Yuya Fujita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
- * E-mail:
| | - Toru Yago
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tomoyuki Asano
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Haruki Matsumoto
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Naoki Matsuoka
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Jumpei Temmoku
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shuzo Sato
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Makiko Yashiro-Furuya
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Eiji Suzuki
- Department of Rheumatology, Ohta-Nishinouchi Hospital, Koriyama, Fukushima, Japan
| | - Hiroshi Watanabe
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
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Maeda-Aoyama N, Hamada-Ode K, Taniguchi Y, Nishikawa H, Arii K, Nakajima K, Fujimoto S, Terada Y. Dyskeratotic cells in persistent pruritic skin lesions as a prognostic factor in adult-onset Still disease. Medicine (Baltimore) 2020; 99:e19051. [PMID: 32028422 PMCID: PMC7015626 DOI: 10.1097/md.0000000000019051] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 12/14/2022] Open
Abstract
Adult-onset Still disease (AOSD), a systemic inflammatory disorder, is characterized by high fever, evanescent rash, arthritis, and hyperferritinaemia. AOSD is also reported to be associated with other skin lesions, including persistent pruritic papules and plaques. This study aimed to assess the significance of dyskeratotic skin lesions in Japanese AOSD patients.We retrospectively assessed the histology of persistent pruritic skin lesions and evanescent rashes and the relationship between dyskeratotic cells, serum markers, and outcomes in 20 Japanese AOSD patients, comparing AOSD histology with that of dermatomyositis (DM), drug eruptions, and graft-versus-host disease (GVHD).As the results, Persistent pruritic lesions were characterized by scattered single keratinocytes with an apoptotic appearance confined to the upper layer of the epidermis and horny layer without inflammatory infiltrate. In contrast to AOSD, the histology of DM, drug eruption, and GVHD demonstrated dyskeratotic cells in all layers of the epidermis with inflammatory infiltrate. AOSD with evanescent rash showed no dyskeratotic cells. The dyskeratotic cells in pruritic AOSD lesions stained positive for ssDNA and terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling, indicating apoptosis. Serum IL-18 was significantly higher in AOSD patients with dyskeratotic cells than those without, and generally required higher doses of glucocorticoids, immunosuppressants, and biologic agents. Two of ten AOSD patients with dyskeratotic cells died from hemophagocytic lymphohistiocytosis.In conclusion, Persistent pruritic AOSD skin lesions are characterized by dyskeratotic cells with apoptotic features, involving the upper layers of the epidermis. There may be a link to elevated IL-18. This dyskeratosis may be a negative prognostic indicator.
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Affiliation(s)
- Natsuki Maeda-Aoyama
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi Medical School Hospital, Nankoku
| | - Kazu Hamada-Ode
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi Medical School Hospital, Nankoku
| | - Yoshinori Taniguchi
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi Medical School Hospital, Nankoku
| | - Hirofumi Nishikawa
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi Medical School Hospital, Nankoku
| | - Kaoru Arii
- Department of Internal Medicine, Kochi Red Cross Hospital, Kochi
| | - Kimiko Nakajima
- Department of Dermatology, Kochi Medical School Hospital, Nankoku, Japan
| | - Shimpei Fujimoto
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi Medical School Hospital, Nankoku
| | - Yoshio Terada
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi Medical School Hospital, Nankoku
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Abstract
OBJECTIVE Adult-onset Still's disease (AOSD) is a rare but clinically well-known polygenic systemic autoinflammatory disease. In this review, we aim to present frontiers in the pathogenesis, clinical features, diagnosis, biomarkers, disease course, prognosis, and treatment in AOSD. DATA SOURCES We retrieved information from the PubMed database up to July 2019, using various search terms and relevant words, including AOSD and Still's disease. STUDY SELECTION We included data from peer-reviewed journals. Both basic and clinical studies were selected. RESULTS Pathogenesis of AOSD involves genetic background, infectious triggers, and immunopathogenesis, mainly the activation of macrophages and neutrophils followed by a cytokine storm. Diagnosis and prognosis evaluation of AOSD is still challenging; therefore, there is an urgent need to identify better biomarkers. Biologic agents, including interleukin (IL)-1β, IL-6, and tumor necrosis factor-α antagonists in the treatment of AOSD, have good prospect. CONCLUSION This review highlights the advances in pathogenesis, potential biomarkers, disease course, and treatment in AOSD.
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Affiliation(s)
- Meng-Yan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Hu QY, Zeng T, Sun CY, Luo CN, Liu S, Ding TT, Ji ZF, Lu A, Yimaiti K, Teng JL, Cheng XB, Ye JN, Su YT, Shi H, Sun Y, Chi HH, Zhou ZC, Chen LJ, Xu J, Jiang LD, Wu LJ, Lin J, Yang CD, Liu HL. Clinical features and current treatments of adult-onset Still's disease: a multicentre survey of 517 patients in China. Clin Exp Rheumatol 2019; 37 Suppl 121:52-57. [PMID: 31573475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 03/25/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES As a rare systemic autoinflammatory disease, adult-onset Still's disease (AOSD) has heterogeneous clinical manifestations, response to treatment and outcome. This study tried to assess the clinical characteristics, laboratory tests, and treatments of Chinese AOSD patients, and make a retrospective analysis. METHODS We collected from 7 hospitals in China a total of 517 Chinese patients with AOSD who satisfied the Yamaguchi criteria. We retrospectively evaluated their clinical features, laboratory tests, treatments and compared them with published data from different studies. All the data in this study were from medical records and further statistic analyses. RESULTS We evaluated a total of 517 AOSD patients, 72% female, average age of onset was 37.7; spiking fever, rash and arthralgia occurred in 472 (91.3%), 413 (79.9%), 378 (73.1%) cases, respectively. There were 439/513 (85.6%) cases with leukocytosis and 456/476 (95.8%) cases with raised serum ferritin. The highest frequently used medications and regimens for remission were glucocorticoids (498/517, 96.3%), methotrexate (273/517, 52.8%) and hydroxychloroquine (174/517, 33.7%). 84.4%. 357/423 of AOSD cases were able to achieve initial remission with different regimens, mostly including glucocorticoids, methotrexate or hydroxychloroquine. 47.2% of them (244/517) received 30<D≤60 mg/d of prednisone to reach final clinical remission. Further analysis indicated that risk factors, such as skin rash, pericarditis, splenomegaly and delayed diagnosis, are highly related to the dosage of prednisone for remission. CONCLUSIONS Glucocorticoids are mostly selected to induce remission in China and half of them required ~0.5-1mg/kgbw prednisone. In patients with skin rash, pericarditis, splenomegaly or delayed diagnosis, a higher dosage of prednisone was needed to obtain remission.
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Affiliation(s)
- Qiong-Yi Hu
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Ruijin Hospital, Shanghai, China
| | - Ting Zeng
- Xinhua Hospital Chongming Branch Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Chuan-Yin Sun
- Department of Rheumatology, First Affiliated Hospital of the Medical School, Zhejiang University, Hangzhou, China
| | - Cai-Nan Luo
- Department of Rheumatology and Immunology, People's Hospital of Xinjiang Ugyur Autonomous Region, Urumqi, China
| | - Shuang Liu
- Department of Rheumatology and Immunology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ting-Ting Ding
- Department of Rheumatology and Immunology, First Affiliated Hospital of Bengbu Medical College, China
| | - Zong-Fei Ji
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Anxin Lu
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kuerbanjiang Yimaiti
- Department of Rheumatology and Immunology, People's Hospital of Xinjiang Ugyur Autonomous Region, Urumqi, China
| | - Jia-Lin Teng
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Ruijin Hospital, Shanghai, China
| | - Xiao-Bing Cheng
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Ruijin Hospital, Shanghai, China
| | - Jun-Na Ye
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Ruijin Hospital, Shanghai, China
| | - Yu-Tong Su
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Ruijin Hospital, Shanghai, China
| | - Hui Shi
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Ruijin Hospital, Shanghai, China
| | - Yue Sun
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Ruijin Hospital, Shanghai, China
| | - Hui-Hui Chi
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Ruijin Hospital, Shanghai, China
| | - Zhuo-Chao Zhou
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Ruijin Hospital, Shanghai, China
| | - Lin-Jie Chen
- Department of Rheumatology and Immunology, First Affiliated Hospital of Bengbu Medical College, China
| | - Jian Xu
- Department of Rheumatology and Immunology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Lin-Di Jiang
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Jun Wu
- Department of Rheumatology and Immunology, People's Hospital of Xinjiang Ugyur Autonomous Region, Urumqi, China
| | - Jin Lin
- Department of Rheumatology, First Affiliated Hospital of the Medical School, Zhejiang University, Hangzhou, China
| | - Cheng-De Yang
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Ruijin Hospital, Shanghai, China.
| | - Hong-Lei Liu
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Ruijin Hospital, Shanghai, China.
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Abstract
Adult-onset Still's disease is a systemic inflammatory disorder of unknown etiology, characterized by skin rash, spiking fever, arthralgias or arthritis, and leukocytosis. The typical skin rash is evanescent, salmon-pink, nonpruritic and maculopapular, predominantly on the extremities. It is considered one of the major Yamaguchi's criteria in adult-onset Still's disease. However, atypical skin lesions are also described. Here, a 61-year-old woman with sore throat, spiking fever, polyarthritis and evanescent salmon-pink nonpruritic maculopapular skin rash on the extremities was diagnosed with adult-onset Still's disease. In addition, atypical brown macules on oral mucosa, localized on the inner lips and tongue were also observed. Biopsy revealed a neutrophilic infiltrate. Despite treatment and improvement of the adult-onset Still's disease, the atypical oral mucosal lesions persisted.
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Affiliation(s)
- María Lorena Brance
- Rheumatology Centre - Rosario, Argentina
- Bone Biology Laboratory. School of Medicine, Universidad Nacional
de Rosario- Rosario, Argentina
- National Council of Scientific and Technical Research (CONICET) -
Rosario, Argentina
| | - Eldo Luis Neffen
- Pathological Anatomy Deparment, Clínica Pergamino -
Pergamino, Argentina
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Anderson CW, Shah PA, Roberts JR. Adult-Onset Still's Disease: Is This Truly a Diagnosis of Exclusion? Hawaii J Med Public Health 2017; 76:3-6. [PMID: 29164007 PMCID: PMC5696586] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Adult-onset Still's Disease is a rare, idiopathic, inflammatory disorder characterized by arthralgia, evanescent, salmon-colored rash, and daily fevers as well as lymphadenopathy, pharyngitis, splenomegaly, myalgias, and serositis. The inciting etiology of this syndrome is unknown, though it has been hypothesized that infection triggers an autoimmune response. The Yamaguchi Criteria, the most sensitive and widely used diagnostic criteria, requires both a minimum set of criteria to be met as well other potential etiologies to be excluded. By definition, evidence of concomitant infection, malignancy, vasculitis, or connective tissue disease precludes the diagnosis of Adult-onset Still's Disease from being made. We present a very rare case of a patient who met all diagnostic criteria for Adult-onset Still's Disease, had a protracted course refractory to numerous immunosuppressant treatments, and also had evidence of coxsackie B infection with fourfold rise in viral titers on two occasions (both associated with disease flare). Although coxsackie B virus has been linked to Adult-onset Still's Disease at disease presentation, this case is unique in its protracted course and serological evidence of infection temporally related to disease flare. While accepted diagnostic criteria call for this disease to be a diagnosis of exclusion, our case supports the fact that ongoing infection may in fact be an important antigenic driver in persistent and refractory Adult-onset Still's Disease.
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Masui-Ito A, Okamoto R, Ikejiri K, Fujimoto M, Tanimura M, Nakamori S, Murata T, Ishikawa E, Yamada N, Imai H, Ito M. Tocilizumab for uncontrollable systemic inflammatory response syndrome complicating adult-onset Still disease: Case report and review of literature. Medicine (Baltimore) 2017; 96:e7596. [PMID: 28723802 PMCID: PMC5521942 DOI: 10.1097/md.0000000000007596] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
RATIONALE Adult-onset Still disease (AOSD) is a rare systemic inflammatory disease of unknown etiology characterized by evanescent salmon-pink rash, fever spikes, arthralgia, and lymphadenopathy. AOSD usually has a good prognosis, but it can sometimes be fatal, especially when it is complicated by systemic inflammatory response syndrome (SIRS) and multiple organ failure. PATIENT CONCERNS A previously healthy 26-year-old woman was referred to our hospital for persistent high fever and mild systemic edema. Five days later, the patient presented with dyspnea, hypotension, and anuria. Anasarca developed with massive pleural effusion, ascites, and systemic edema, resulting in an increase of 47 kg in body weight. DIAGNOSES The patient was diagnosed as AOSD after infection, malignancy, hematologic disorders, and other autoimmune diseases were excluded. INTERVENTIONS We administered tocilizumab, an IL-6 receptor inhibitor, intravenously in addition to cyclosporine, prednisolone, plasma exchange, and continuous hemodiafiltration. OUTCOMES The patient's systemic condition improved. After stabilization by all medications, the patient was managed and responded to tocilizumab alone. To the best of our knowledge, this was the first case of severe SIRS complicating AOSD that was successfully treated with an anti- IL-6 receptor antibody. LESSONS SIRS should not be overlooked in a patient with steroid-resistant AOSD and edema. Inhibitors of the IL-6 receptor can be used safely and effectively to control AOSD complicated with severe SIRS.
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Affiliation(s)
| | - Ryuji Okamoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Kaoru Ikejiri
- Emergency and Critical Care Center, Mie University Hospital
| | - Mika Fujimoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Muneyoshi Tanimura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Shiro Nakamori
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Tomohiro Murata
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Eiji Ishikawa
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Norikazu Yamada
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiroshi Imai
- Emergency and Critical Care Center, Mie University Hospital
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
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Narváez Garcia FJ, Pascual M, López de Recalde M, Juarez P, Morales-Ivorra I, Notario J, Jucglà A, Nolla JM. Adult-onset Still's disease with atypical cutaneous manifestations. Medicine (Baltimore) 2017; 96:e6318. [PMID: 28296747 PMCID: PMC5369902 DOI: 10.1097/md.0000000000006318] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The diagnosis of adult-onset Still's disease (AOSD) can be very difficult. There are no specific tests available, and diagnosis is usually based on a symptom complex and the well-described typical evanescent rash seen in the majority of patients. However, in recent years, other atypical cutaneous manifestations of AOSD have been reported. These atypical skin eruptions often present in addition to the typical evanescent rash but may also be the only skin manifestation, resulting in delayed diagnosis because of under-recognition.In this study, we present 3 new cases of AOSD with atypical cutaneous manifestations diagnosed during a 30-year period in our department and review 78 additional cases previously reported (PubMed 1990-2016). These 81 patients form the basis of the present analysis.The overall prevalence of atypical cutaneous manifestations in our AOSD population was 14%. These manifestations may appear at any time over the course of the disease, and usually occur in patients who have persistent and severe disease, with a considerable frequency of clinical complications (23%), including serositis, myopericarditis, lung involvement, abdominal pain, neurologic involvement, and reactive hemophagocytic syndrome.The most representative and frequent lesion among the nonclassical skin rashes is the development of persistent pruritic papules and/or plaques. Interestingly, these lesions show a distinctive histological pattern. Other, less frequently observed lesions include urticaria and urticaria-like eruptions, generalized or widespread non-pruritic persistent erythema, vesiculopustular eruptions, a widespread peau d'orange appearance of the skin, and edema of the eyelids mimicking dermatomyositis without any accompanying skin lesion.The great majority of these patients required medium or high doses of glucocorticoids (including intravenous methylprednisolone pulse therapy in some cases) and, in nearly 40%, a more potent or maintenance immunotherapy with immunosuppressant drugs and/or biologic agents (mainly anakinra or tocilizumab) to control or manage symptoms because of a polycyclic or chronic course. The development of atypical cutaneous manifestations seems to be associated with a potentially worse prognosis, with a mortality rate reaching 8% primarily because of infectious complications related to immunosuppressive therapy.In conclusion, the appearance of atypical cutaneous manifestations is not uncommon in AOSD. Recognition of this clinical variant is crucial for the early diagnosis of AOSD, as it might imply persistent disease activity and the need for more aggressive treatment.
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Affiliation(s)
| | | | | | | | | | - Jaime Notario
- Department of Dermatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, Spain
| | - Anna Jucglà
- Department of Dermatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, Spain
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Woody M, Keeling B, Gavino A. Hyperpigmented papules and plaques. Cutis 2017; 99:E1-E3. [PMID: 28319629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Meghan Woody
- Graduate Medical Education Transitional Program, Dell Medical School, University of Texas at Austin, USA
| | - Brett Keeling
- Department of Dermatology, Dell Medical School, University of Texas at Austin, USA
| | - Alde Gavino
- Department of Dermatology, Dell Medical School, University of Texas at Austin, USA
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12
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Gerfaud-Valentin M, Cottin V, Jamilloux Y, Hot A, Gaillard-Coadon A, Durieu I, Broussolle C, Iwaz J, Sève P. Parenchymal lung involvement in adult-onset Still disease: A STROBE-compliant case series and literature review. Medicine (Baltimore) 2016; 95:e4258. [PMID: 27472698 PMCID: PMC5265835 DOI: 10.1097/md.0000000000004258] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Parenchymal lung involvement (PLI) in adult-onset Still's disease (AOSD) has seldom, if ever, been studied. We examine here retrospective cohort AOSD cases and present a review of the literature (1971-2014) on AOSD-related PLI cases.Patients with PLI were identified in 57 AOSD cases. For inclusion, the patients had to fulfill Yamaguchi or Fautrel classification criteria, show respiratory symptoms, and have imaging evidence of pulmonary involvement, and data allowing exclusion of infectious, cardiogenic, toxic, or iatrogenic cause of PLI should be available. This AOSD + PLI group was compared with a control group (non-PLI-complicated AOSD cases from the same cohort).AOSD + PLI was found in 3 out of the 57 patients with AOSD (5.3%) and the literature mentioned 27 patients. Among these 30 AOSD + PLI cases, 12 presented an acute respiratory distress syndrome (ARDS) and the remaining 18 another PLI. In the latter, a nonspecific interstitial pneumonia computed tomography pattern prevailed in the lower lobes, pulmonary function tests showed a restrictive lung function, the alveolar differential cell count was neutrophilic in half of the cases, and the histological findings were consistent with bronchiolitis and nonspecific interstitial pneumonia. Corticosteroids were fully efficient in all but 3 patients. Ten out of 12 ARDS cases occurred during the first year of the disease course. All ARDS-complicated AOSD cases received corticosteroids with favorable outcomes in 10 (2 deceased). Most PLIs occurred during the systemic onset of AOSD.PLI may occur in 5% of AOSDs, of which ARDS is the most severe. Very often, corticosteroids are efficient in controlling this complication.
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Affiliation(s)
- Mathieu Gerfaud-Valentin
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix Rousse, Service de Médecine Interne
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
- Correspondence: Mathieu Gerfaud-Valentin, Hospices Civils de Lyon, Hôpital Universitaire de la Croix Rousse, Service de Médecine Interne, 103 Grande Rue de la Croix Rousse, F-69004 Lyon, France (e-mail: )
| | - Vincent Cottin
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
- Hospices civils de Lyon, Hôpital Louis Pradel, Centre national de référence des maladies pulmonaires rares, centre de compétences de l’hypertension pulmonaire, service de pneumologie, Bron
| | - Yvan Jamilloux
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix Rousse, Service de Médecine Interne
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
| | - Arnaud Hot
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne, Lyon
| | - Agathe Gaillard-Coadon
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix Rousse, Service de Médecine Interne
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
| | - Isabelle Durieu
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service de Médecine Interne, Pierre-Bénite
| | - Christiane Broussolle
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix Rousse, Service de Médecine Interne
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
| | - Jean Iwaz
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
- Hospices Civils de Lyon, Service de Biostatistique, Lyon
- CNRS UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Équipe Biostatistique Santé, Pierre-Bénite, France
| | - Pascal Sève
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix Rousse, Service de Médecine Interne
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
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Sakairi T, Hiromura K, Kaneko Y, Maeshima A, Hirato J, Nojima Y. Histological findings in the spleen affected by adult-onset Still's disease: a report of three cases. Clin Exp Rheumatol 2016; 34:566-567. [PMID: 26841850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 10/05/2015] [Indexed: 06/05/2023]
Affiliation(s)
- Toru Sakairi
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine, Gunma, Japan.
| | - Keiju Hiromura
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yoriaki Kaneko
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Akito Maeshima
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Junko Hirato
- Department of Pathology, Gunma University Hospital, Gunma, Japan
| | - Yoshihisa Nojima
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine, Gunma, Japan
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14
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Hotta E, Nakai N, Katoh N. Persistent pruritic eruptions in adult-onset Still's disease: additional histopathological findings. Acta Dermatovenerol Croat 2015; 23:146-147. [PMID: 26228828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
| | - Noriaki Nakai
- Department of Dermatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kajii-cho, Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan;
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Umeda M, Origuchi T, Fujikawa K, Koga T, Mizokami A, Nakashima Y, Suzuki T, Okada A, Kawashiri SY, Ichinose K, Tamai M, Yamasaki S, Nakamura H, Kawakami A, Eguchi K. Hemophagocytic syndrome and inflammatory myopathy with abundant macrophages in a patient with adult-onset Still's disease. Intern Med 2014; 53:2385-9. [PMID: 25318809 DOI: 10.2169/internalmedicine.53.1081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein describe a 71-year-old woman with adult-onset Still's disease (AOSD) who developed fever, myalgia, and pancytopenia. The bone marrow aspiration and muscle biopsy revealed hemophagocytic syndrome (HPS) and inflammatory myopathy with abundant macrophages (IMAM). Immunostained specimens were positive for expression of retinoic acid-inducible gene-I (RIG-I), which recognizes viral RNA in infiltrated mononuclear cells as well as muscle tissues. These findings suggest that RIG-I may be involved in induction of HPS and IMAM in AOSD.
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Affiliation(s)
- Masataka Umeda
- Department of Rheumatology, Graduate School of Biomedical Sciences, Nagasaki University, Japan
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16
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Affiliation(s)
- Yung-Tsu Cho
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, 15 F, No.7, Chung-Shan S. Rd., Taipei 10002, Taiwan
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Inoue R, Kato T, Kim F, Mizushima I, Murata T, Yoshino H, Kawano M, Yamagishi M. A case of adult-onset Still's disease (AOSD)-like manifestations abruptly developing during confirmation of a diagnosis of metastatic papillary thyroid carcinoma. Mod Rheumatol 2012; 22:796-800. [PMID: 22270347 DOI: 10.1007/s10165-011-0588-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 12/22/2011] [Indexed: 11/25/2022]
Abstract
A 68-year-old Japanese man was admitted to our hospital suffering from abrupt onset of high fever accompanied by arthralgia, myalgia, sore throat, macular eruption, and liver dysfunction. Six months before the onset of these manifestations, (18)F-fluoro-deoxy-glucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) had detected, unexpectedly, three calcified thyroid lesions without (18)F-FDG uptake. Two months before the onset of the present manifestations, ultrasonography-guided fine-needle aspiration had led to a diagnosis of papillary thyroid carcinoma (PTC). Soon after the occurrence of the rheumatic manifestations, a subsequent (18)F-FDG PET/CT scan showed not only the three thyroid lesions, the same as those in the previous scan, but also (18)F-FDG uptake in the thyroid lesion. A diagnosis of adult-onset Still's disease (AOSD)-like manifestations associated with PTC was made, and treatment with 40 mg/day of prednisolone (PSL) resolved the symptoms promptly. PSL was gradually tapered, without recurrence of the (AOSD)-like manifestations. Five months after the initiation of treatment with PSL, total thyroidectomy, followed by (131)I thyroid ablation treatment, was performed while the patient was on a PSL dose of 18 mg/day. Seven months after the thyroidectomy, the dose of PSL was tapered to 2 mg/day, and neither the AOSD-like manifestations nor the PTC relapsed. On confirming a diagnosis of AOSD, it may be necessary to consider the presence of an associated malignancy, including solid tumors such as PTC.
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Affiliation(s)
- Ryo Inoue
- Division of Rheumatology, Ishikawa Prefectural Central Hospital, 2-1 Kuratsuki-higashi, Kanazawa 920-8530, Japan
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Yamamoto T. Cutaneous manifestations associated with adult-onset Still's disease: important diagnostic values. Rheumatol Int 2011; 32:2233-7. [PMID: 22198666 DOI: 10.1007/s00296-011-2330-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 12/10/2011] [Indexed: 11/24/2022]
Abstract
Adult-onset Still's disease (AOSD) is a systemic inflammatory condition, characterized by a high spiking fever, leukocytosis with neutrophilia, arthralgia, and skin rash. Typical skin rash is an evanescent, salmon-pink erythema predominantly involving extremities, which is included as one of the diagnostic criteria; however, recent findings show that not only typical evanescent rash but also various skin lesions are associated with AOSD. The representative characteristic skin lesion among the non-classical skin rash is called persistent pruritic papules and plaques, which presents erythematous, slightly scaly papules with linear configuration on the trunk. Interestingly, persistent pruritic papules and plaques show unique histological features such as peculiar, distinctive distribution of dyskeratotic keratinocytes in the cornified layers as well as in the epidermis. Other non-classical skin lesions include urticaria. Current insights suggest that several inflammatory cytokines such as interleukin-1 (IL-1), IL-6, IL-18, interferon-γ (IFN-γ) and tumor necrosis factor-α (TNF-α) play a pathogenic role in AOSD. In particular, IL-18 is suggested to play a crucial role in activating macrophages, favoring Th1 type cytokine production. IL-18 induces IFN-γ, IL-17, and TNF-α, which may play an important pathogenic role in AOSD. It is important to recognize the common and/or uncommon skin conditions of AOSD for early correct diagnosis. In this review, various skin lesions are introduced, and the complication with histiocytic necrotizing lymphadenitis (Kikuchi disease) is further discussed.
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Affiliation(s)
- Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University, Hikarigaoka 1, Fukushima 960-1295, Japan.
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Fujii K, Kitamura Y, Osugi Y, Koyama Y, Ota T. A case of adult-onset Still's disease complicated by hemophagocytic syndrome and interstitial pneumonia with pneumomediastinum/recurrent pneumothorax. Int J Rheum Dis 2011; 15:e60-2. [PMID: 22898226 DOI: 10.1111/j.1756-185x.2011.01691.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
MESH Headings
- Antirheumatic Agents/therapeutic use
- Cyclosporine/therapeutic use
- Drug Therapy, Combination
- Female
- Glucocorticoids/therapeutic use
- Humans
- Lung Diseases, Interstitial/complications
- Lung Diseases, Interstitial/drug therapy
- Lung Diseases, Interstitial/pathology
- Lymphohistiocytosis, Hemophagocytic/complications
- Lymphohistiocytosis, Hemophagocytic/drug therapy
- Lymphohistiocytosis, Hemophagocytic/pathology
- Mediastinal Emphysema/complications
- Mediastinal Emphysema/drug therapy
- Mediastinal Emphysema/pathology
- Middle Aged
- Pneumothorax/complications
- Pneumothorax/pathology
- Pneumothorax/therapy
- Prednisolone/therapeutic use
- Recurrence
- Still's Disease, Adult-Onset/complications
- Still's Disease, Adult-Onset/drug therapy
- Still's Disease, Adult-Onset/pathology
- Thoracic Surgical Procedures
- Treatment Outcome
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20
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Zhao DB, Dai SM, Liu XP, Xu H. Interstitial inflammation in visceral organs is a pathologic feature of adult-onset Still's disease. Rheumatol Int 2009; 31:923-7. [PMID: 19882158 DOI: 10.1007/s00296-009-1228-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Accepted: 10/07/2009] [Indexed: 12/19/2022]
Abstract
The pathological features of adult-onset Still's disease remain unclear. An original case study of the histopathological changes in various organs of a patient with the disorder is presented. Interstitial inflammation was found in the heart, lung, liver, mucosa of total alimentary canal, and urinary bladder. Previous reports that involved the pathology of visceral organs are also reviewed.
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Affiliation(s)
- Dong-Bao Zhao
- Department of Rheumatology and Immunology, Changhai Hospital, Second Military Medical University, 174 Changhai Road, 200433, Shanghai, China
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21
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Nakamura M, Kobayashi M, Tokura Y. A novel missense mutation in tumour necrosis factor receptor superfamily 1A (TNFRSF1A) gene found in tumour necrosis factor receptor-associated periodic syndrome (TRAPS) manifesting adult-onset Still disease-like skin eruptions: report of a case and review of the Japanese patients. Br J Dermatol 2009; 161:968-70. [PMID: 19673872 DOI: 10.1111/j.1365-2133.2009.09409.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Gesierich A, Stoevesandt J, Kneitz C, Bröcker EB, Schön MP. Adult-onset Still's disease: an uncommon differential diagnosis of urticaria and treatment with anakinra. J Eur Acad Dermatol Venereol 2009; 23:104-6. [PMID: 18429988 DOI: 10.1111/j.1468-3083.2008.02746.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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Kieffer C, Cribier B, Lipsker D. Neutrophilic urticarial dermatosis: a variant of neutrophilic urticaria strongly associated with systemic disease. Report of 9 new cases and review of the literature. Medicine (Baltimore) 2009; 88:23-31. [PMID: 19352297 DOI: 10.1097/md.0b013e3181943f5e] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
We conducted the current study to define within the spectrum of the neutrophilic dermatoses a group of patients with an urticarial rash clinically and a neutrophilic dermatosis histopathologically. We reviewed the literature on neutrophilic urticaria and we report here a series of patients with this unique presentation. We reviewed all cutaneous biopsies submitted to our department between 2000 and 2006 in which histopathologic evaluation was compatible with this entity. We then retrieved the patient medical records and obtained information about follow-up and associated diseases. This allowed us to identify 9 patients with an urticarial eruption that was characterized histopathologically by a perivascular and interstitial neutrophilic infiltrate with intense leukocytoclasia but without vasculitis and without dermal edema. Four patients also had small foci of necrobiotic collagen bundles. The eruption consisted of pale, flat or only slightly raised, nonpruritic macules, papules, or plaques. Elementary lesions resolved within 24 hours. Purpura, angioedema, and facial swelling were not seen, but dermographism was present in 1 patient. Six patients had fever, 7 had polyarthritis, and 6 had leukocytosis. Seven patients had associated systemic diseases: adult-onset Still disease (3 patients), systemic lupus erythematosus (3 patients), and Schnitzler syndrome (1 patient).A similar rash has been reported previously in the literature, mostly in patients with systemic inflammatory diseases, but the majority of patients reported under the undefined designation of "neutrophilic urticaria" did have a different clinicopathologic presentation. Thus, we suggest naming this eruption "neutrophilic urticarial dermatosis," to emphasize that this entity expands the broad group of cutaneous manifestations of neutrophilic aseptic disease. This entity bears important medical significance as it is strongly indicative of an associated systemic disease, mainly Schnitzler syndrome, adult-onset Still disease, lupus erythematosus, and the hereditary autoinflammatory fever syndromes.
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Affiliation(s)
- Carine Kieffer
- From the Université Louis Pasteur, Faculté de Médecine et Clinique Dermatologique, Hôpitaux Universitaires, Strasbourg, France
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24
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Geurts DEM, van der Velden WJFM, Hebeda KM, Raemaekers JMM. Richter's syndrome developing in a patient with adult onset Still's disease. Ann Hematol 2008; 88:81-4. [PMID: 18607590 DOI: 10.1007/s00277-008-0526-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2007] [Accepted: 06/03/2008] [Indexed: 11/28/2022]
MESH Headings
- Adult
- Diagnosis, Differential
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/physiopathology
- Lymphoma, Non-Hodgkin/etiology
- Lymphoma, Non-Hodgkin/immunology
- Lymphoma, Non-Hodgkin/pathology
- Lymphoma, Non-Hodgkin/physiopathology
- Middle Aged
- Still's Disease, Adult-Onset/complications
- Still's Disease, Adult-Onset/immunology
- Still's Disease, Adult-Onset/pathology
- Still's Disease, Adult-Onset/physiopathology
- Syndrome
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25
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Lin KM, Lai JH, Chang CC, Lin CK, Chang DM, Chen CH. Formation of numerous rice bodies: an unusual finding of adult-onset Still's disease. Clin Rheumatol 2008; 27 Suppl 2:S55-7. [PMID: 18509715 DOI: 10.1007/s10067-008-0900-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Accepted: 04/03/2008] [Indexed: 11/30/2022]
Abstract
Adult-onset Still's disease (AOSD) is an inflammatory disorder characterized by high-spiking fever, arthritis, and an evanescent rash. The pattern of chronic arthritis is a universal feature of AOSD. However, chronic bursitis with the formation of numerous rice bodies is a very rare presentation in a patient with AOSD. To our knowledge, no case of formation of numerous rice bodies in AOSD has been reported thus far. We describe the case of a 28-year-old man with AOSD with rice bodies in his left shoulder joint.
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Affiliation(s)
- Kang-Min Lin
- Division of Rheumatology/Immunology/Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan, Republic of China
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Funauchi M, Ikoma S, Kishimoto K, Shimazu H, Nozaki Y, Sugiyama M, Kinoshita K. A case of adult onset Still’s disease showing marked accumulation in the liver and spleen, on positron emission tomography–CT images. Rheumatol Int 2008; 28:1061-4. [PMID: 18443796 DOI: 10.1007/s00296-008-0562-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2007] [Accepted: 03/08/2008] [Indexed: 11/26/2022]
Affiliation(s)
- Masanori Funauchi
- Department of Nephrology and Rheumatology, Kinki University School of Medicine, Osaka-Sayama, Osaka 589-8511, Japan.
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27
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Abstract
We studied the clinical profile, laboratory parameters, disease course, and outcomes of patients with adult onset Still's disease (AOSD). A retrospective analysis of adult patients with Still's disease diagnosed from 2000 to 2004 was carried out. Their clinical features and laboratory findings at presentation, disease course, and outcomes were analyzed. Data of 14 patients with Still's disease were analyzed. The age at disease onset ranged from 16 to 59 years with a mean of 29.85, the male to female ratio being 9:5. The mean duration of illness from onset of symptoms to presentation was 14.5 months (range). The most common clinical manifestations were fever (n = 14), articular symptoms (n = 14), rash (n = 8), weight loss (n = 12), and sore throat (n = 5). Elevated ESR was present in all patients with a mean of 98.3 mm at 1 h. Hepatic enzymes were elevated in seven patients at disease onset. The mean duration of follow up was 19.14 months (range). Three patients progressed to chronic arthropathy. Cyclosporine led to dramatic recovery in five patients. Macrophage activation syndrome (MAS) was present in two patients, one after sulfasalazine therapy. One patient with MAS died. Still's disease, although uncommon, has characteristic constellation of clinical and laboratory features and should be considered in the differential diagnosis of fever of unknown origin. Nonsteroidal anti-inflammatory drugs, steroids, and methotrexate may not be always effective, and cyclosporine is an effective drug in resistant cases. Sulfasalazine should be avoided in cases of AOSD.
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Affiliation(s)
- S Singh
- Department of Rheumatology, P.D. Hinduja National Hospital & Medical Research Center, V.S Marg, Mahim (w), Mumbai-16, India
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28
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Woo JH, Seong SS, Yoo DH. Association of interleukin 18 polymorphisms with adult onset Still's disease in Korea. J Rheumatol 2007; 34:1637-9. [PMID: 17611971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
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Abstract
Adult-onset Still disease (AOSD) is an uncommon disorder characterized by fever, polyarthralgia, elevated white blood cell count, and a maculopapular rash, the histologic features of which have not been well-known. A 55-year-old Asian woman presented initially with a "burning" and severely pruritic eruption on her face, hands, and arms, thought clinically to be urticaria. Within 1 month, she began spiking high fevers, developed diffuse joint pain, and had marked elevations of ferritin, C-reactive protein, and erythrocyte sedimentation rate, characteristic of AOSD. The cutaneous eruption became more widespread, involving the trunk, scalp, and remainder of the extremities, with diffuse thickening of the skin with papular and linear hyperpigmentation and accentuation. Biopsies from several locations showed focal hyperkeratosis associated with dyskeratotic keratinocytes with a peculiar, distinctive distribution in the upper epidermis and cornified layers. In addition, increased dermal mucin was present, with minimal fibroblast proliferation and inflammation. This unusual combination of diffuse dermal mucinosis and a unique pattern of dyskeratosis can present a challenge in generating an accurate differential diagnosis, and may represent an unusual response to chronic scratching or be a distinctive histologic manifestation of AOSD.
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Affiliation(s)
- Greg Wolgamot
- Department of Pathology, University of Washington, Seattle, WA 98195-6100, USA
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30
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Lee SW, Park MC, Kim H, Park YB, Lee SK. Dermatopathic lymphadenopathy in a patient with adult onset Still's disease. Clin Exp Rheumatol 2007; 25:312-4. [PMID: 17543161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Adult onset Still's disease (AOSD) is a systemic inflammatory disorder of unknown cause characterized by high fever accompanied by systemic manifestations. Since AOSD consists of heterogeneous symptoms and has no definite diagnostic tool, the diagnosis is based upon exclusive criteria. Dermatopathic lymphadenopathy (DL) is characterized by a localized paracortical proliferation of histiocytes and deposition of melanin in the lymph nodes. DL is not only a reactive hyperplasia of the lymph nodes, but has also been reported to be associated with hematological malignancies such as cutaneous T cell lymphoma (CTCL) and Hodgkin's lymphoma. It is therefore important to evaluate CTCL or Hodgkin's lymphoma in a patient with DL, in order to both rule out hematological malignancy and diagnose AOSD. In this report, we first describe a 37-year-old patient with AOSD whose biopsy of lymph node was proved to be DL.
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Affiliation(s)
- S-W Lee
- Division of Rheumatology, Department of Internal Medicine, Institute for Immunology and Immunological Disease, BK21 Project for Medical science, Yonsei University College of Medicine, Shinchon-dong, Seoul, Korea
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31
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Uppal SS, Al-Mutairi M, Hayat S, Abraham M, Malaviya A. Ten years of clinical experience with adult onset Still’s disease: is the outcome improving? Clin Rheumatol 2006; 26:1055-60. [PMID: 17086384 DOI: 10.1007/s10067-006-0440-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2006] [Revised: 09/06/2006] [Accepted: 09/07/2006] [Indexed: 11/28/2022]
Abstract
This study aims to report on the clinical and laboratory picture and the disease course and outcome in patients having adult onset Still's disease (AOSD), to briefly review existing literature on the subject, and to compare our findings with those previously reported. Results are reported for 28 patients with AOSD satisfying the preliminary criteria of Yamaguchi et al. seen in a teaching hospital over the last 10 years. A high percent of the patients with AOSD were women. The mean (+SD) age at disease onset was 27.8 (+8.4) years. We found fever in 100%, rash in 85%, arthritis in 64%, lymphadenopathy in 60%, splenomegaly in 57%, hepatomegaly in 35%, pleural effusion in 17.9%, and pericardial effusion in 3.6% of our patients. Leukocytosis was present in 96% of the patients, a normochromic, normocytic anemia in 54%, and an elevated erythrocyte sedimentation rate (ESR) in all. Serum ferritin levels were raised in 89% of the patients. The mean follow-up of the patients was 3.72 + 2.46 years. The mean delay in diagnosis was 7.32 + 18.0 months. The mean time to enter remission was 9.7 months. Self-limited, intermittent, and chronic disease course was seen in 14.3, 57.1, and 28.6% of patients, respectively. The outcome was good in about 89% of patients, and mortality was nil. No particular clinical or laboratory variable was found to predict the subsequent disease course and outcome in our patients. On comparing our data with important previous series, we found a higher percentage of women and of patients presenting in the age group 16-35 years, a lower frequency of arthritis and pericardial effusion, and some other notable differences. Importantly, the disease course was benign, probably as an outcome of heightened awareness and less diagnostic delay than in the past, allowing for early, aggressive, and appropriate treatment. It is concluded that AOSD is now a relatively benign disease if diagnosed early and treated appropriately.
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Affiliation(s)
- Sukhbir Singh Uppal
- Rheumatology Division, Department of Medicine, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait.
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Tabata R, Tabata C, Fukuda H, Kotani H. Expansion of large granular lymphocytes following Pseudomonas infection in a patient with adult-onset Still's disease. Mod Rheumatol 2006; 16:101-4. [PMID: 16633930 DOI: 10.1007/s10165-006-0462-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Accepted: 02/14/2006] [Indexed: 11/29/2022]
Abstract
We report a patient who had a 4-year history of adult-onset Still's disease (AOSD) and showed a prominent increase in large granular lymphocytes (LGL) when she developed severe Pseudomonas conjunctivitis due to Pseudomonas aeruginosa, skin eruptions, liver damage, and abnormal findings in coagulation studies, without any evidence of active viral activation, hemophagocytosis, or malignancies. The increased LGL cells were CD3(+)CD8(+), and disappeared promptly after the administration of antibiotics combined with prednisolone, with subsequent stabilization of her general condition.
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Affiliation(s)
- Rie Tabata
- Department of Internal Medicine, Hyogo Prefectural Tsukaguchi Hospital, 6-8-17 Minamitsukaguchi, Amagasaki, 661-0012, Japan.
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Dziadzio M, Hamdulay S, Reddy V, Boyce S, Keat A, Andrews J. A still image of a transient rash captured by a mobile phone. Clin Rheumatol 2006; 26:979-80. [PMID: 16586047 DOI: 10.1007/s10067-006-0221-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Revised: 01/19/2006] [Accepted: 01/19/2006] [Indexed: 11/30/2022]
Abstract
The diagnosis of adult onset Still's disease (AOSD) can be difficult as the differential diagnosis is broad, it is based on clinical criteria and the signs, for example rash, can be transient. Clinical photography has an obvious role, and with modern technology, is now in the hands of physicians. We report a case of AOSD where an image of a transient rash taken with a camera phone allowed the diagnosis to be established. Further, we discuss the controversies around hospital bans on mobile phones (due to potential incompatibility with medical devices) and the reality of their widespread use. We conclude that, providing safeguards of consent and data storage are in place, the camera phone is a useful tool in rheumatology practice.
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Affiliation(s)
- Magdalena Dziadzio
- Arthritis Centre, Northwick Park Hospital, Watford Road, Harrow, London, HA1 3UJ, UK.
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Abstract
A 34-year-old woman with adult-onset Still's disease (AOSD) developed prurigo pigmentosa-like lesions on her chest and upper back in addition to the typical rash of AOSD. A biopsy specimen taken from the upper back showed characteristic features of prurigo pigmentosa. The eruption and fever subsided immediately after the administration of 40 mg/day prednisolone, but arthralgia persisted even after intravenous pulse methylprednisolone therapy in combination with immunosuppressive drugs. Various atypical skin rashes, including prurigo pigmentosa-like lesions, have been reported in association with AOSD. Therefore, one should carefully follow the clinical course of a patient in order not to overlook these atypical cutaneous manifestations of AOSD.
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Affiliation(s)
- Kahori Tomaru
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan.
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Pay S, Türkçapar N, Kalyoncu M, Simşek I, Beyan E, Ertenli I, Oztürk MA, Düzgün N, Erdem H, Ozbalkan Z, Kiraz S, Kinikli G, Besbas N, Dinç A, Ateş A, Olmez U, Calgüneri M, Aydintuğ OT, Bakkaloğlu A, Turan M, Turgay M, Karaaslan Y, Topaloğlu R, Duman M, Ozen S. A multicenter study of patients with adult-onset Still’s disease compared with systemic juvenile idiopathic arthritis. Clin Rheumatol 2005; 25:639-44. [PMID: 16365690 DOI: 10.1007/s10067-005-0138-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2005] [Revised: 06/16/2005] [Accepted: 06/19/2005] [Indexed: 12/01/2022]
Abstract
Adult-onset Still's disease (AOSD) has often been regarded as the adult spectrum of systemic juvenile idiopathic arthritis (sJIA). The present study aims to compare the clinical and laboratory features, the disease course and the response to treatment in patients having AOSD with those having sJIA. Retrospective review of all available data that were filled out by adult and paediatric rheumatologists from six centers using a standard data extraction form was performed. A total of 95 patients with AOSD and 25 patients with sJIA were recruited for the study. The frequency of fever, rash, myalgia, weight loss and sore throat was higher in patients with AOSD. The pattern of joint involvement differed slightly. Laboratory findings were similar in both groups, except that liver dysfunction and neutrophilia were more common among adults. A multiphasic pattern dominated the childhood cases, whereas the most frequent course was a chronic one in adults. Corticosteroids and methotrexate were the most commonly employed therapy; however, chloroquine was another popular therapy in the adult group. We showed a difference in the rate of clinical and laboratory features between patients with AOSD and those with sJIA. AOSD and sJIA may still be the same disease, and children may simply be reacting differently as the result of the first encounter of the putative antigens with the immune system.
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Affiliation(s)
- Salih Pay
- Division of Rheumatology, Gulhane Military School of Medicine, Ankara, Turkey
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Kato T, Fujii K, Wakabayashi T, Tanaka A, Hidaka Y. A case of cutaneous polyarteritis nodosa manifested by spiking high fever, arthralgia and macular eruption like adult-onset Still's disease. Clin Rheumatol 2005; 25:419-21. [PMID: 16234994 DOI: 10.1007/s10067-005-0022-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2005] [Accepted: 03/22/2005] [Indexed: 11/29/2022]
Abstract
A 24-year-old Japanese woman was admitted for investigation of recurrent spiking high fever associated with a macular eruption of the upper extremities associated with fever and polyarthralgia. These symptoms were self-limiting but recurrent and seemed to be consistent with a diagnosis of adult-onset Still's disease (AOSD). However, livedo reticularis was detected on the lower extremities, suggesting the presence of vasculitic disease rather than AOSD. Investigation did not reveal any evidence of visceral involvement. Skin biopsy of the affected lower extremity demonstrated a necrotizing vasculitis of small muscular artery and confirmed a diagnosis of cutaneous polyarteritis nodosa (PAN) rather than AOSD. Treatment with 30 mg of prednisolone daily improved the skin lesions and the recurrent spiking high fever and the arthralgia were resolved. PAN and AOSD are clinically similar, and discrimination may be sometimes difficult. The presence of livedo reticularis and the finding of a characteristic skin biopsy appearance may be diagnostically useful to distinguish PAN from AOSD. Indeed, the clinical features of cutaneous PAN may be more similar to AOSD than systemic PAN, and a skin biopsy may be necessary to distinguish cutaneous PAN from AOSD in some cases.
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Affiliation(s)
- Takashi Kato
- Department of Rheumatology, Kameda Medical Center, 929 Higashi-cho, Chiba, Kamogawa City 296-8602, Japan.
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Kumari R, Uppal SS. Prolonged remission in adult-onset Still’s disease with etanercept. Clin Rheumatol 2005; 25:106-8. [PMID: 15856368 DOI: 10.1007/s10067-004-1064-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2004] [Accepted: 11/18/2004] [Indexed: 10/25/2022]
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Jeon YK, Paik JH, Park SS, Park SO, Kim YA, Kim JE, Song YW, Kim CW. Spectrum of lymph node pathology in adult onset Still's disease; analysis of 12 patients with one follow up biopsy. J Clin Pathol 2004; 57:1052-6. [PMID: 15452159 PMCID: PMC1770453 DOI: 10.1136/jcp.2004.018010] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Adult onset Still's disease (AOSD) is a rare systemic inflammatory disorder of unknown aetiology, frequently accompanying multiple lymphadenopathy. It often mimics malignant lymphoma, and immunohistochemical and molecular studies are needed for definite diagnosis. AIMS To aid in diagnosis and understand the pathogenesis of the disease by clarifying lymph node (LN) pathology in AOSD. METHODS Thirteen biopsies (one follow up biopsy) and medical records of 12 patients were reviewed. Immunohistochemistry, polymerase chain reaction for T cell receptor gamma chain (TCRgamma) and immunoglobulin heavy chain gene rearrangement, and Epstein-Barr virus in situ hybridisation were performed. RESULTS Histologically, LN lesions were classified into four patterns. The most common (six biopsies) showed paracortical hyperplasia, with prominent vascular proliferation, scattered large B/T immunoblasts, and infiltration by reactive lymphocytes and inflammatory cells. In the second pattern (two biopsies), paracortical hyperplasia was accompanied by massive sinus histiocytosis and S-100 positive histiocyte aggregates. The third pattern (three patients) showed an exuberant immunoblastic reaction, in the form of patchy/diffuse infiltration of large T immunoblasts with high mitotic activity, although clonal rearrangement of the TCRgamma gene was not detected. The fourth pattern showed distinct follicular hyperplasia (two cases). One patient with a follow up biopsy showed a pattern change from pronounced follicular hyperplasia to atypical paracortical hyperplasia. CONCLUSIONS AOSD LN lesions show a dynamic histological spectrum, including atypical paracortical hyperplasia, burnt out histiocytic reaction, exuberant immunoblastic reaction, and follicular hyperplasia. During the course of disease, LN reactivity changes and mixed B and T cells are involved in the pathogenesis.
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Affiliation(s)
- Y K Jeon
- Department of Pathology and Cancer Research Institute, Tumour Immunity Medical Research Centre, Seoul National University College of Medicine, Seoul 110-799, Korea
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Abstract
A TRIAD OF FEATURES: Adult onset Still's disease (ASD) is an uncommon disorder usually associating high spiking fever, evanescent skin rash constituted of small salmon pink macules, and arthritis. NUMEROUS SYSTEMIC MANIFESTATIONS: A sore throat is common and often misleading. More than 60% of the patients develop mobile and indolent lymph nodes, usually in the cervical area. Liver involvement is common and usually limited to a mild or moderate cytolysis. However, several observations of severe hepatitis have been reported justifying strict monitoring of the liver biology in these patients. Amongst the other numerous systemic manifestations that have been reported, pericarditis is common and sometimes responsible for tamponade, the pulmonary involvement may lead to an acute respiratory distress, and the rare neurological manifestations include aseptic meningitis or cranial nerve palsy. FROM A BIOLOGICAL POINT OF VIEW: The sedimentation rate is consistently elevated and there is usually a marked elevation in the polymorphonuclears. The bacteriological survey is negative as are the immunological tests. An increase in the serum level of IL-18 might be both diagnostic and prognostic. It is the increase of the serum level of ferritin and the marked decrease in its glycosylated fraction below 20% that seem to be of more potent diagnostic value.
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Affiliation(s)
- Jacques Pouchot
- Service de médecine interne V, Hôpital Louis Mourier, Colombes.
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Abstract
DIAGNOSTIC DOUBTS: Despite an increased awareness of the clinical features of the disease, adult onset Still's disease (AOSD) remains a diagnosis of exclusion. Many diagnostic criteria have been published, and the most popular are those proposed by Yamaguchi, even though they do not consider the presence of hyperferritinemia or the decrease of it glycosylated fraction, and they include exclusion criteria that are difficult to satisfy. UNPREDICTABLE PROGRESSION: Three evolutive forms have been described: monocyclic, intermittent with articular and/or systemic flares, chronic, usually in the form of chronic polyarthritis. Vital prognosis is sometimes compromised by severe systemic manifestations or the occurrence of amyloidosis, whilst destructive polyarthritis, particularly common in the chronic form, may compromise the function. The aetiology of AOSD remains unknown. THERAPEUTIC UNCERTAINTIES: Treatment is largely empirical in the absence of randomized clinical trials because of the rarity of the disease. Nonsteroidal anti-inflammatory drugs could be used in moderately severe forms of the disease, but they rare rarely sufficient. Around 80% of the patients require corticosteroids. Among the disease modifying drugs, methotrexate still remains the most effective. The role of the new anti-TNF molecules remains to be specified.
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Affiliation(s)
- Jacques Pouchot
- Service de médecine interne V, Hôpital Louis Mourier, Colombes.
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Chen DY, Lan JL, Lin FJ, Hsieh TY. Proinflammatory cytokine profiles in sera and pathological tissues of patients with active untreated adult onset Still's disease. J Rheumatol 2004; 31:2189-98. [PMID: 15517632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
OBJECTIVE To investigate concentrations of proinflammatory cytokines in the sera and their mRNA expression in biopsy specimens of evanescent rash and synovitis from patients with active untreated adult onset Still's disease (AOSD). METHODS We measured serum levels of interleukin 6 (IL-6), IL-8, and tumor necrosis factor (TNF-alpha) by immunochemiluminescence method and serum IL-18 levels by ELISA in 50 patients with active untreated AOSD, 20 patients with active rheumatoid arthritis (RA), and 20 healthy controls. Multivariate analysis was used to evaluate the correlation between serum cytokine levels and disease activity and clinical features of AOSD. We also evaluated the expression of cytokine transcripts by real-time quantitative polymerase chain reaction in biopsy specimens of evanescent rash and synovitis from 12 patients with active untreated AOSD. RESULTS Significantly higher levels of IL-6, IL-8, IL-18, and TNF-alpha in sera were found in patients with active untreated AOSD compared to healthy controls. Serum levels of IL-6 and IL-18 correlated well with clinical activity score of AOSD patients. Multiple logistic regression analysis showed that serum IL-6 level was a possible predictor for the occurrence of evanescent rash (p = 0.0593), serum IL-8 level was a significant predictor of persistent arthritis, and serum IL-18 level predicted occurrence of liver dysfunction. The levels of mRNA expression of IL-6, IL-18, and IL-8 were significantly higher in the biopsy tissue of Still's rash from AOSD patients compared with those in controls. Levels of mRNA expression of IL-18, IL-8, and TNF-alpha were significantly higher in the synovial membranes of AOSD patients compared with those in osteoarthritis controls. Significantly lower levels of TNF-alpha and IL-8 were found in the sera and in the synovial membranes of AOSD patients compared with those in RA patients. AOSD patients who had a chronic articular course had significantly higher levels of serum IL-8 compared with those who had a monocyclic systemic course. CONCLUSION Significantly higher levels of IL-6, IL-8, IL-18, and TNF-alpha were seen in both sera and pathological tissues of patients with active AOSD. The associations between levels of cytokine profile and distinct clinical manifestations and various patterns of disease course suggest the heterogeneity of pathogenesis in AOSD.
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Affiliation(s)
- Der-Yuan Chen
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
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Abstract
Adult-onset Still's disease (AOSD) is a systemic inflammatory disorder of unknown etiology and pathogenesis. AOSD is a rare condition, usually presenting with high fever accompanied by systemic manifestations. The disease is a heterogeneous pathological entity with a range of etiologies, manifestations and prognosis. There is no single diagnostic test for AOSD; rather, the diagnosis is based upon clinical criteria such as arthralgia, fever, skin rash, lymphadenopathy, and hepatosplenomegaly. Determination of the procalcitonin level and the biological response to empirical corticosteroid therapy generally helps the diagnosis, while immune-serology, as a 'screening' test, will not add meaningful information in most cases. Treatment consists of anti-inflammatory medications. Non-steroid anti-inflammatory drugs have limited efficacy, corticosteroid therapy and disease-modifying antirheumatic drugs are usually required. Novel therapeutic approaches, such as anti-tumor necrosis factor blockade and stem cell transplantation, are promising. In this chapter we present clinical and laboratory parameters of 18 patients diagnosed with AOSD at our institution between 1997 and 2003, and review the literature.
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Affiliation(s)
- János Kádár
- 6th Department for Internal Medicine, Szent László Hospital Budapest, Fovárosi Szent László Kórház, Gyáli út 5-7, 1097 Budapest, Hungary.
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Prendiville JS, Tucker LB, Cabral DA, Crawford RI. A pruritic linear urticarial rash, fever, and systemic inflammatory disease in five adolescents: adult-onset still disease or systemic juvenile idiopathic arthritis sine arthritis? Pediatr Dermatol 2004; 21:580-8. [PMID: 15461768 DOI: 10.1111/j.0736-8046.2004.21513.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The characteristic rash of systemic juvenile idiopathic arthritis is a transient erythematous eruption associated with a quotidian spiking fever. Usually asymptomatic, it can be pruritic, with dermatographism at sites of scratching or pressure. An illness similar to this entity in adults is designated adult-onset Still disease. The relationship between the pediatric and adult disease is uncertain and differences in case definition have evolved. Specifically, a sustained arthritis for at least 6 weeks is required for a diagnosis of systemic juvenile idiopathic arthritis, whereas transient arthritis and arthralgia are accepted criteria in adult-onset Still disease. We describe five patients less than 16 years of age who presented with an acute illness characterized by fever and a distinctive skin eruption. Intense pruritus and linear erythematous lesions flared with a spiking fever, usually in the late afternoon and evening. Periorbital edema/erythema and nonlinear urticarial lesions were also seen. Two children had splinter hemorrhages of the nail beds and one girl developed a fixed, scaling, pigmented, linear eruption. Severe malaise, myalgia, arthralgia, and leukocytosis were present in every patient. Other systemic manifestations included sore throat, transient arthritis, abdominal pain, lymphadenopathy, hepatomegaly, splenomegaly, hyperferritinemia, and hepatic dysfunction. No patient had a sustained arthritis. The course of the disease was variable. One patient, diagnosed with macrophage activation syndrome, recovered on oral naproxen. Two patients responded to systemic corticosteroid therapy. One girl developed status epilepticus and died from aspiration and asphyxia. A boy with severe hepatitis developed renal failure and thrombotic thrombocytopenic purpura and was treated with plasmapheresis, dialysis, and systemic corticosteroids; he had recurrent episodes of rash and fever into adult life. These children did not fulfill the case definition of systemic juvenile idiopathic arthritis because they lacked a persistent arthritis. Adolescent and adult patients with the same clinical and laboratory findings are described under the rubric of adult-onset Still disease. Recognition of the distinctive urticarial skin eruption and spiking fever is important in the diagnosis of a disease with severe morbidity and potentially life-threatening complications.
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Affiliation(s)
- Julie S Prendiville
- Division of Pediatric Dermatology, Department of Pediatrics, British Columbia's Children's Hospital, Vancouver, British Columbia, Canada
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Chung JW, Suh YJ, Song HJ, Choi JH, Park HS, Cho SR, Suh CH. Pure red cell aplasia and adult-onset Still?s disease. Clin Rheumatol 2004; 23:368-70. [PMID: 15293104 DOI: 10.1007/s10067-004-0899-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2003] [Accepted: 01/23/2004] [Indexed: 10/26/2022]
Abstract
Pure red cell aplasia (PRCA) associated with adult-onset Still's disease (AOSD) is very rare. In this report a 28-year-old woman was admitted with fever, skin rash, jaundice and anemia. She was diagnosed as having AOSD with PRCA by bone marrow examination. Treatment with high-dose prednisolone and intravenous immunoglobulin resulted in remission of the PRCA and a good response of the AOSD.
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Affiliation(s)
- Jae-Wook Chung
- Department of Allergy-Rheumatology, Ajou University School of Medicine, Paldal-gu, Suwon, Korea
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Park JH, Bae JH, Choi YS, Lee HS, Jun JB, Jung S, Yoo DH, Bae SC, Kim TH. Adult-onset Still's disease with disseminated intravascular coagulation and multiple organ dysfunctions dramatically treated with cyclosporine A. J Korean Med Sci 2004; 19:137-41. [PMID: 14966357 PMCID: PMC2822251 DOI: 10.3346/jkms.2004.19.1.137] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [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: 11/21/2022] Open
Abstract
Severe systemic manifestations of adult onset Still's disease (AOSD) are often fatal and occasionally related to hemophagocytic syndrome (HS). We describe the case of a 49-yr-old woman with AOSD presenting with non-remitting high fever, confusion, jaundice, hepatosplenomegaly, serositis, azotemia, pancytopenia, coagulopathy with disseminated intravascular coagulation (DIC), hyperferritinemia, acute acalculous cholecystitis and ileocolitis noted in computed tomographic images. The patient had a history of herpes zoster developed prior to the admission, but there is no history of diarrhea or abdominal pain. Although bone marrow examination was not performed due to hemorrhagic diathesis, we suspected AOSD-associated HS on the basis of clinical course without detectable infectious agents in cultures or serologic studies. Intravenous immunoglobulin, pulse methylprednisolone, oral cyclosporine A (CsA) and ceftriaxone brought about transient improvement of fever and confusion, but the disease progressed. After increasing CsA dose, all previously mentioned abnormalities disappeared rapidly. Accordingly, we believe that DIC and multiple organ dysfunctions might have been the complications of HS but not that of sepsis, and that CsA can be used as a first-line therapy in case of life-threatening situations.
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Affiliation(s)
- Jae-Hong Park
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Joong Ho Bae
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Yeon-Soo Choi
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Hye-Soon Lee
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Jae-Bum Jun
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Sungsoo Jung
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Dae-Hyun Yoo
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Sang-Cheol Bae
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Tae-Hwan Kim
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
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Gambichler T, Paech V, Rotterdam S, Stücker M, Boms S, Altmeyer P. Hepatitis B-assocciated adult-onset Still's disease presenting with neutrophilic urticaria. Eur J Med Res 2003; 8:527-30. [PMID: 14711598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023] Open
Abstract
Adult-onset Still's disease (AOSD) is an uncommon systemic inflammatory disorder that is characterized by quotidian fever, articular manifestations, neutrophilic leukocytosis, and maculopapular rash. The aetiology of the disease is unknown, however, an infectious cause has been suggested. Here we describe a patient in whom neutrophilic urticaria was the cutaneous manifestation of AOSD. In addition, the patient suffered from chronic hepatitis B infection that may be a potential trigger factor of AOSD. In patients with AOSD, serological investigations for detection of infection should include hepatitis serology. Further, we suggest that urticarial lesions may be a more common cutaneous manifestation of AOSD than has been recognized previously. Thus it is important to include AOSD in the differential diagnosis of urticaria.
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Affiliation(s)
- T Gambichler
- Dermatology Out-Patient Clinic, Oldchurch Hospital, Romford (Greater East London), United Kingdom.
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Abstract
OBJECTIVE Peripheral neutrophilia is one of characteristic laboratory findings in patients with adult Still's disease (ASD). We performed this study to identify the bone marrow findings in patients ASD. METHODS We examined 12 bone marrow biopsy specimens from patients with ASD. RESULTS The most frequent finding was granulocyte hyperplasia (12/12, 100%) and hypercellularity was observed in 75.0% (8/12) of patients. Plasmacytosis was present in 8.3% (1/12) of specimens. Histiocytosis and reactive hemophagocytosis were found in 25.0% (4/12) and in 16.7% (2/12) respectively. CONCLUSION Our results show that bone marrow granulocyte hyperplasia is the main possible mechanism for peripheral neutrophilia and that histiocytic activation is a not infrequent bone marrow findings in patients with ASD.
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Affiliation(s)
- Jun-Ki Min
- Holy Family Hospital, College of Medicine, The Catholic University of Korea, Kyunggi-Do, South Korea.
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Manganelli P, Fietta P, Zuccoli P. Adult-onset Still's disease with respiratory distress syndrome, polyserositis and disseminated intravascular coagulation: a case with a fatal outcome. Clin Exp Rheumatol 2003; 21:139. [PMID: 12673909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
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Abstract
Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder of unknown etiology characterized by an evanescent rash, intermittent spiking high fever, arthralgia, and a variety of systemic features. We describe a 46-yr-old woman with Still s disease who presented with a 2-month history of a symmetrical vesiculopustular eruptions only on both hands and feet. Skin biopsy specimens of both vesicle and pustule revealed fibrin thrombi deposition in the small dermal vessels with little inflammation, subepidermal bulla, and ischemic necrosis of the overlying epidermis, which were consistent with a vasculopathic reaction. Her skin lesions gradually disappeared in response to conventional AOSD therapy, as elevated serum ferritin levels, an index of disease activity, decreased. To the best of our knowledge, this is the first case of vesiculopustular lesions as a skin manifestation of AOSD.
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Affiliation(s)
- Jee Bum Lee
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea.
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