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Wang L, Suo L, Kou F, Zhang Y, Li M, Wang H, Casalino G, Peto T, Chakravarthy U, Wang Y, Wu W, Dong N. Ocular Phenotypes in Patients With Hemophagocytic Lymphohistiocytosis: A Retrospective Analysis in a Single Center Over 7 Years. Am J Ophthalmol 2023; 253:119-131. [PMID: 37178948 DOI: 10.1016/j.ajo.2023.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE To investigate the presence and type of ocular abnormalities in patients with hemophagocytic lymphohistiocytosis (HLH). DESIGN A retrospective cross-sectional study. METHODS Observational report of ocular findings and their associations with age, sex, underlying disease, and hematologic parameters. HLH was defined according to the 2004 criteria, and the patients were enrolled from March 2013 to December 2021. Analysis began in July 2022 and ended in January 2023. The main outcome measures were ocular abnormalities associated with HLH and their potential risk factors. RESULTS Of 1525 HLH patients, 341 had ocular examinations, and 133 (133 of 341, 39.00%) had ocular abnormalities. Mean age at presentation was 30.21 ± 14.42 years. The multivariate analysis indicated that old age, autoimmune disorders, decreasing red blood cell count, decreasing platelet count, and increasing fibrinogen level were independent risk factors of ocular involvement in HLH patients. The most common presenting ocular findings were posterior segment abnormalities (66 patients, 49.62%), including retinal and vitreous hemorrhage, serous retinal detachment, cytomegalovirus retinitis, and optic disc swelling. Other HLH-associated ocular abnormalities included ocular surface infection (conjunctivitis, 34 patients, 25.56%; keratitis, 16 patients, 12.03%), subconjunctival hemorrhage (11 patients, 8.27%), chemosis (5 patients, 3.76%), anterior uveitis (11 patients, 8.27%), glucocorticoid-induced glaucoma (5 patients, 3.76%), radiation cataract (1 patient, 0.75%), dacryoadenitis (2 patients, 1.50%), dacryocystitis (1 patients, 0.75%), orbital cellulitis (2 patients, 1.50%), orbital pseudotumor (2 patients, 1.50%), and strabismus (2 patients, 1.50%). CONCLUSIONS Eye involvement is not uncommon in HLH. Better awareness among both ophthalmologists and hematologists is necessary for prompt diagnosis and institution of appropriate management strategies with potential to save sight and life.
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Affiliation(s)
- Luping Wang
- From the Department of Ophthalmology, Beijing Friendship Hospital, Capital Medical University (L.W., Y.Z., M.L., Y.W., W.W., N.D.), Beijing, China
| | - Lingge Suo
- Department of Ophthalmology, Peking University Third Hospital (L.S.), Beijing, China; Beijing Key Laboratory of Restoration of Damaged Ocular Nerve, Peking University Third Hospital (L.S.), Beijing, China
| | - Fangning Kou
- Department of Ophthalmology, Beijing Anzhen Hospital, Capital Medical University (F.K.), Beijing, China
| | - Youjing Zhang
- From the Department of Ophthalmology, Beijing Friendship Hospital, Capital Medical University (L.W., Y.Z., M.L., Y.W., W.W., N.D.), Beijing, China
| | - Mingming Li
- From the Department of Ophthalmology, Beijing Friendship Hospital, Capital Medical University (L.W., Y.Z., M.L., Y.W., W.W., N.D.), Beijing, China
| | - Hao Wang
- Department of Clinical Epidemiology and Evidence-Based Medicine, Beijing Clinical Research Institute, Beijing Friendship Hospital, Capital Medical University (H.W.), Beijing, China
| | - Giuseppe Casalino
- Eye Clinic, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, University of Milan (G.C.), Milan, Italy
| | - Tunde Peto
- Centre for Public Health, Queen's University of Belfast (T.P., U.C.), Belfast, United Kingdom
| | - Usha Chakravarthy
- Centre for Public Health, Queen's University of Belfast (T.P., U.C.), Belfast, United Kingdom
| | - Yanling Wang
- From the Department of Ophthalmology, Beijing Friendship Hospital, Capital Medical University (L.W., Y.Z., M.L., Y.W., W.W., N.D.), Beijing, China
| | - Weizhen Wu
- From the Department of Ophthalmology, Beijing Friendship Hospital, Capital Medical University (L.W., Y.Z., M.L., Y.W., W.W., N.D.), Beijing, China
| | - Ning Dong
- From the Department of Ophthalmology, Beijing Friendship Hospital, Capital Medical University (L.W., Y.Z., M.L., Y.W., W.W., N.D.), Beijing, China.
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Sun Z, Li R, Wang Y, Han F, Wei W, Li X. Efficacy of Baricitinib in Patients with Refractory Adult-Onset Still's Disease. Drugs R D 2023:10.1007/s40268-023-00417-7. [PMID: 37010773 DOI: 10.1007/s40268-023-00417-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Adult-onset Still's disease (AOSD) is an idiopathic systemic inflammatory disease of unknown aetiology. Some patients exhibit resistance to conventional treatment during long-term therapy. Janus kinase inhibitors (JAKinibs) may contribute to the improvement in AOSD symptoms via the JAK-signal transducer and activator of transcription (STAT) pathway. We aimed to explore the efficacy and safety of baricitinib in patients with refractory AOSD. METHODS Patients were enrolled if they fulfilled the Yamaguchi AOSD classification criteria in China between 2020 and 2022. All patients were recognized as having refractory AOSD and were treated with oral baricitinib at a dosage of 4 mg once daily. A systemic score and prednisone dosage were used to evaluate the efficacy of baricitinib at months 1, 3, and 6 and at the last follow-up visit. The safety profiles were recorded and analysed at every assessment. RESULTS Seven female patients with refractory AOSD received baricitinib. The median age was 31 (IQR 10) years. Treatment was terminated in one patient due to progressive macrophage activation syndrome (MAS). Others continued baricitinib treatment until the last assessment. The systemic score decreased significantly at 3 months (p = 0.0216), 6 months (p = 0.0007), and the last follow-up visit (p = 0.0007) compared with baseline. One month after the initiation of baricitinib, the rates of improvement in fever, rash, sore throat, and myalgia symptoms were 71.4% (5/7), 40% (2/5), 80% (4/5), and 66.7% (2/3), respectively. Five patients remained symptom-free at the last follow-up visit. In most patients, their laboratory values had returned to normal by the last follow-up visit. A significant reduction in the levels of C-reactive protein (CRP) (p = 0.0165) and ferritin (p = 0.0047) was observed at the last visit compared with baseline. The daily prednisolone dosage significantly decreased from 35.7 ± 15.1 mg/day at baseline to 8.8 ± 4.4 mg/day by month 6 (p = 0.0256), and it was 5.8 ± 4.7 mg/day at the last assessment (p = 0.0030). Leukopenia due to MAS was noted in one patient. Except for mild abnormalities in lipid parameters, no other severe adverse events occurred during follow-up. CONCLUSIONS Our findings suggest that baricitinib therapy could provide rapid and durable clinical and laboratory improvement in patients with refractory AOSD. Treatment seemed to be well tolerated by these patients. The long-term efficacy and safety of baricitinib therapy for AOSD should be assessed further in prospective controlled clinical trials in the future. TRIAL REGISTRATION Trial registration number (TRN): ChiCTR2200061599. Date of registration: 29 June 2022 (retrospectively registered).
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Affiliation(s)
- Ziyi Sun
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
- Tianjin Clinical Research Center for Rheumatic and Immune Diseases, Tianjin, 300052, People's Republic of China
| | - Rongqi Li
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
- Tianjin Clinical Research Center for Rheumatic and Immune Diseases, Tianjin, 300052, People's Republic of China
| | - Yingai Wang
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
- Tianjin Clinical Research Center for Rheumatic and Immune Diseases, Tianjin, 300052, People's Republic of China
| | - Feng Han
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
- Tianjin Clinical Research Center for Rheumatic and Immune Diseases, Tianjin, 300052, People's Republic of China
| | - Wei Wei
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
- Tianjin Clinical Research Center for Rheumatic and Immune Diseases, Tianjin, 300052, People's Republic of China
| | - Xin Li
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China.
- Tianjin Clinical Research Center for Rheumatic and Immune Diseases, Tianjin, 300052, People's Republic of China.
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Shi N, Wang X, Zou L, Yang X, Ma Q, Lu M. Case Report: Macrophage Activation Syndrome and Widespread Neuroimaging Abnormality in Childhood-Onset Systemic Lupus Erythematosus. Front Pediatr 2021; 9:767115. [PMID: 34970517 PMCID: PMC8713754 DOI: 10.3389/fped.2021.767115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/17/2021] [Indexed: 11/13/2022] Open
Abstract
Macrophage activation syndrome (MAS) and widespread brain lesions are rare and severe complications of childhood-onset systemic lupus erythematosus (SLE). We report an 11-year-old girl who presented with recurrent rashes for half a year and fever for 2 weeks. Clinical and laboratory features at admission pointed to the diagnosis of SLE and SLE-associated MAS. Cerebral magnetic resonance imaging taken on day 4 after admission showed abnormal signals. Glucocorticoid therapy was started on day 5. Two days later, the patient appeared weak and ill, then the next day she exhibited dizziness, drowsiness, apathia, and dysarthria. High-dose methylprednisolone, cyclophosphamide, and intravenous immunoglobulin were used to treat the patient, and intrathecal dexamethasone was given. The patient was discharged on day 30 after admission and showed complete clinical resolution and improved magnetic resonance imaging resolution.
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Affiliation(s)
- Nana Shi
- Department of Hematology-Oncology, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | | | - Lixia Zou
- Department of Rheumatology Immunology and Allergy, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Xinghui Yang
- Department of Radiology, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Qian Ma
- Department of Rheumatology Immunology and Allergy, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Meiping Lu
- Department of Rheumatology Immunology and Allergy, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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Klein C, Kleinschmidt-DeMasters BK, Liang X, Stence N, Tuder RM, Moore BE. A Review of Neuropathological Features of Familial and Adult Hemophagocytic Lymphohistiocytosis. J Neuropathol Exp Neurol 2019; 78:197-208. [DOI: 10.1093/jnen/nlz001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Colleen Klein
- Department of Pathology, University of Colorado School of Medicine, Aurora, Colorado
| | - B K Kleinschmidt-DeMasters
- Department of Pathology, University of Colorado School of Medicine, Aurora, Colorado
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Xiayuan Liang
- Department of Pathology, Children’s Hospital of Colorado, Aurora, Colorado
| | - Nicholas Stence
- Department of Neuroradiology, Children’s Hospital of Colorado, Aurora, Colorado
| | - Rubin M Tuder
- Department of Pathology, University of Colorado School of Medicine, Aurora, Colorado
| | - Brian E Moore
- Department of Pathology, University of Colorado School of Medicine, Aurora, Colorado
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Marsh RA. Epstein-Barr Virus and Hemophagocytic Lymphohistiocytosis. Front Immunol 2018; 8:1902. [PMID: 29358936 PMCID: PMC5766650 DOI: 10.3389/fimmu.2017.01902] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/13/2017] [Indexed: 12/29/2022] Open
Abstract
Epstein–Barr virus (EBV) is a ubiquitous virus that infects nearly all people worldwide without serious sequela. However, for patients who have genetic diseases which predispose them to the development of hemophagocytic lymphohistiocytosis (HLH), EBV infection is a life-threatening problem. As a part of a themed collection of articles on EBV infection and human primary immune deficiencies, we will review key concepts related to the understanding and treatment of HLH.
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Affiliation(s)
- Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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Sebrow DB, Dhrami-Gavazi E, Horowitz JD, Yannuzzi LA. PURTSCHER RETINOPATHY AS A MANIFESTATION OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS. Retin Cases Brief Rep 2018; 11:335-338. [PMID: 27472512 DOI: 10.1097/icb.0000000000000360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
PURPOSE The authors describe a woman diagnosed with hemophagocytic lymphohistiocytosis and found to have retinal examination findings consistent with Purtscher retinopathy. METHODS A 52-year-old woman underwent multimodal imaging, including color fundus photography and spectral-domain optical coherence tomography, to confirm the diagnosis. RESULTS The ophthalmic examination and imaging confirmed the findings of Purtscher retinopathy with significant inner retinal thickening on spectral-domain optical coherence tomography. Throughout a hospital course complicated by multi-organ failure, she continued to have profoundly limited visual acuity, likely resulting from inner retinal ischemia affecting the posterior pole of both eyes. CONCLUSION The authors describe a patient with hemophagocytic lymphohistiocytosis, a disease characterized by disruption of normal natural killer cell activity with subsequent uncontrolled cytokine release, who presented with Purtscher retinopathy confirmed with spectral-domain optical coherence tomography.
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Affiliation(s)
- Dov B Sebrow
- *Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University College of Physicians and Surgeons, New York, New York; †Vitreous Retina Macular Consultants of New York, New York, New York; and ‡LuEsther T. Mertz Retinal Research Center, Manhattan Eye, Ear, and Throat Institute, New York, New York
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Buyukavsar C, Karagoz E, Sonmez M, Kar T, Kaya A, Düzgun E, Yildirim Y. A Rare Ocular Manifestation of Adult Onset Still's Disease: Purtscher's-like Retinopathy. Ocul Immunol Inflamm 2016; 26:286-291. [PMID: 27599266 DOI: 10.1080/09273948.2016.1213857] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Adult-onset Still's disease (AOSD) is a rare multisystemic immune-mediated disease of unknown etiology with quotidian spiking fever, evanescent rash, arthralgia, and multiple organ involvement. The few AOSD cases that have been reported developed Purtscher's-like retinopathy associated with thrombotic microangiopathy (TMA). Here, we report Purtscher's-like retinopathy without TMA in a patient with AOSD. A 29-year-old-man who presented for evaluation of blurred vision was diagnosed with AOSD based on Yamaguchi criteria. He had Purtscher's-like retinopathy in his right eye. Lesions improved after steroid treatment. Although almost all reported AOSD cases with Purtscher's-like retinopathy are associated with TMA, in this case such a complication was not encountered.
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Affiliation(s)
- Cihan Buyukavsar
- a Department of Ophthalmology , Gulhane Military Medical Academy Haydarpasa Training Hospital , Uskudar , Istanbul , Turkey
| | - Ergenekon Karagoz
- b Department of Infectious Diseases and Clinical Microbiology , Gulhane Military Medical Academy Haydarpasa Training Hospital , Uskudar , Istanbul , Turkey
| | - Murat Sonmez
- a Department of Ophthalmology , Gulhane Military Medical Academy Haydarpasa Training Hospital , Uskudar , Istanbul , Turkey
| | - Taner Kar
- a Department of Ophthalmology , Gulhane Military Medical Academy Haydarpasa Training Hospital , Uskudar , Istanbul , Turkey
| | - Abdullah Kaya
- a Department of Ophthalmology , Gulhane Military Medical Academy Haydarpasa Training Hospital , Uskudar , Istanbul , Turkey
| | - Eyup Düzgun
- a Department of Ophthalmology , Gulhane Military Medical Academy Haydarpasa Training Hospital , Uskudar , Istanbul , Turkey
| | - Yildiray Yildirim
- a Department of Ophthalmology , Gulhane Military Medical Academy Haydarpasa Training Hospital , Uskudar , Istanbul , Turkey
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Successful Tocilizumab Therapy for Macrophage Activation Syndrome Associated with Adult-Onset Still's Disease: A Case-Based Review. Case Rep Med 2016; 2016:5656320. [PMID: 27688774 PMCID: PMC5027298 DOI: 10.1155/2016/5656320] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/07/2016] [Accepted: 08/11/2016] [Indexed: 01/13/2023] Open
Abstract
We report the case of a 71-year-old Japanese woman with adult-onset Still's disease (AOSD) in whom macrophage activation syndrome (MAS) developed despite therapy with oral high-dose prednisolone and intravenous methylprednisolone pulse therapy twice. She was successfully treated with tocilizumab (TCZ). Soon afterward, her fever ceased and high levels of both ferritin and C-reactive protein levels decreased. Her course was complicated by disseminated intravascular coagulation, cytomegalovirus infection, and Pneumocystis jirovecii pneumonia. After these were resolved, AOSD-associated MAS was well controlled. She was discharged on hospital day 87. Although biologics such as TCZ are becoming established for the treatment of AOSD, there is no recommended therapy for AOSD-associated MAS. Several biologics have been tried for this complication, but their efficacy and safety remain controversial. We reviewed reported cases of AOSD-associated MAS successfully treated with various biologics. TCZ initiation after adequate nonselective immunosuppressive therapy, such as methylprednisolone pulse therapy or a prednisolone-based combination of immunosuppressants, can be an effective treatment for AOSD-associated MAS. On the other hand, biologics given after insufficient immunosuppressive therapy may cause MAS. A strategy combining adequate immunosuppression and a biologic could be safe if special attention is given to adverse events such as opportunistic infections or biologic-associated MAS.
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Macrophage activation syndrome complicating adult onset Still’s disease: A single center case series and comparison with literature. Semin Arthritis Rheum 2016; 45:711-6. [DOI: 10.1016/j.semarthrit.2015.11.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 08/31/2015] [Accepted: 11/06/2015] [Indexed: 01/22/2023]
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Brito-Zerón P, Bosch X, Pérez-de-Lis M, Pérez-Álvarez R, Fraile G, Gheitasi H, Retamozo S, Bové A, Monclús E, Escoda O, Moreno A, López-Guillermo A, Khamashta MA, Ramos-Casals M. Infection is the major trigger of hemophagocytic syndrome in adult patients treated with biological therapies. Semin Arthritis Rheum 2015; 45:391-9. [PMID: 26277577 DOI: 10.1016/j.semarthrit.2015.07.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 07/07/2015] [Accepted: 07/09/2015] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Hemophagocytic syndromes (hemophagocytic lymphohistiocytosis, HLH) are characterized by a wide range of etiologies, symptoms, and outcomes, but have a common etiopathogenic pathway leading to organ damage: an excessive inflammatory response. Biological therapies have been proposed as a therapeutic option for refractory HLH, but have also been related to the development of HLH in severe immunosuppressed patients. OBJECTIVES AND METHODS The purpose of this study was to analyze the clinical characteristics and outcomes of adult patients who developed HLH after receiving biological therapies. RESULTS We identified 30 patients (29 from the PubMed search and one unpublished case), including 19 women and 11 men, with a mean age of 46.5 years. Underlying diseases consisted of rheumatologic/autoimmune diseases in 24 patients and hematological neoplasia in the remaining 6. Biological agents received before the development of HLH were mainly anti-TNF agents (n = 19). Search for microorganisms confirmed systemic infection in 20 (67%) patients, including Mycobacterium tuberculosis (n = 5), cytomegalovirus (CMV) (n = 4), Epstein-Barr virus (EBV) (n = 3), Histoplasma capsulatum (n = 3), Escherichia coli (n = 2), Staphylococcus aureus, Leishmania amastigotes and Brucella melitensis (n = 1, respectively); viral infections were mainly reported in inflammatory bowel disease (IBD) patients. Patients with infections had more frequently received previous immunosuppressive therapies (p = 0.036) and had lower leukocyte counts (p = 0.020) in comparison with patients without associated infections. The outcome was described in 29 patients. After a mean follow-up of 6.3 months, 8 patients died (28%) and 6 had received anti-TNF agents. There was a high mortality rate in patients aged >65 years and those with tuberculosis (62% and 60%, respectively). CONCLUSIONS In patients receiving biological therapies who develop HLH, searching for a concomitant infectious process is mandatory, and specific surveillance for EBV/CMV infections (in patients with IBD) and for bacteria, including mycobacteria (in elderly patients receiving anti-TNF therapy), is recommended.
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Affiliation(s)
- Pilar Brito-Zerón
- Josep Font Laboratory of Autoimmune Diseases, CELLEX-Institut d׳Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Department of Systemic Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - Xavier Bosch
- Department of Internal Medicine, Hospital Clínic, Barcelona, Spain
| | | | | | - Guadalupe Fraile
- Department of Internal Medicine, Hospital Ramón y Cajal, Madrid, Spain
| | - Hoda Gheitasi
- Josep Font Laboratory of Autoimmune Diseases, CELLEX-Institut d׳Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Soledad Retamozo
- Josep Font Laboratory of Autoimmune Diseases, CELLEX-Institut d׳Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Albert Bové
- Josep Font Laboratory of Autoimmune Diseases, CELLEX-Institut d׳Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ester Monclús
- Department of Internal Medicine, Hospital Clínic, Barcelona, Spain
| | - Ona Escoda
- Department of Internal Medicine, Hospital Clínic, Barcelona, Spain
| | - Asunción Moreno
- Department of Infectious Diseases (ICMiD), Hospital Clínic, Barcelona, Spain
| | | | - Munther A Khamashta
- Lupus Research Unit, The Rayne Institute, St Thomas׳ Hospital, King׳s College University, London, UK
| | - Manuel Ramos-Casals
- Josep Font Laboratory of Autoimmune Diseases, CELLEX-Institut d׳Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Department of Systemic Autoimmune Diseases, Hospital Clínic, Barcelona, Spain.
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Gold CA, Sheth SJ, Agarwal S, Claassen J, Foreman B. New-onset seizures in two adults with hemophagocytic lymphohistiocytosis. J Neurol 2015; 262:1063-5. [DOI: 10.1007/s00415-015-7669-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 02/04/2015] [Accepted: 02/05/2015] [Indexed: 10/24/2022]
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Kobayashi D, Ito S, Murasawa A, Narita I, Nakazono K. Two cases of adult-onset Still's disease treated with tocilizumab that achieved tocilizumab-free remission. Intern Med 2015; 54:2675-9. [PMID: 26466710 DOI: 10.2169/internalmedicine.54.4935] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
There have been many previously reported cases of adult-onset Still's disease (AOSD) which were successfully treated with tocilizumab (TCZ). However, the efficacy and safety of TCZ therapy for AOSD-associated macrophage activation syndrome (MAS), and the optimal duration of TCZ therapy, remain unclear. We herein report two cases of refractory AOSD, one of which was associated with MAS. These two patients were treated with TCZ, and the withdrawal of TCZ was planned according to the serum interleukin-6 level, which resulted in TCZ-free remission.
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Maria ATJ, Le Quellec A, Jorgensen C, Touitou I, Rivière S, Guilpain P. Adult onset Still's disease (AOSD) in the era of biologic therapies: dichotomous view for cytokine and clinical expressions. Autoimmun Rev 2014; 13:1149-59. [PMID: 25183244 DOI: 10.1016/j.autrev.2014.08.032] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 06/03/2014] [Indexed: 01/10/2023]
Abstract
Adult onset Still's disease (AOSD) is a rare inflammatory disorder characterized by hectic spiking fever, evanescent rash and joint involvement. Prognosis is highly variable upon disease course and specific involvements, ranging from benign and limited outcome to chronic destructive polyarthritis and/or life-threatening events in case of visceral complications or reactive hemophagocytic lymphohistiocytosis (RHL). AOSD remains a debatable entity at the frontiers of autoimmune diseases and autoinflammatory disorders. The pivotal role of macrophage cell activation leading to a typical Th1 cytokine storm is now well established in AOSD, and confirmed by the benefits using treatments targeting TNF-α, IL-1β or IL-6 in refractory patients. However, it remains difficult to determine predictive factors of outcome and to draw guidelines for patient management. Herein, reviewing literature and relying on our experience in a series of 8 refractory AOSD patients, we question nosology and postulate that different cytokine patterns could underlie contrasting clinical expressions, as well as responses to targeted therapies. We therefore propose to dichotomize AOSD according to its clinical presentation. On the one hand, 'systemic AOSD' patients, exhibiting the highest inflammation process driven by excessive IL-18, IL-1β and IL-6 production, would be at risk of life-threatening complications (such as multivisceral involvements and RHL), and would preferentially respond to IL-1β and IL-6 antagonists. On the other hand, 'rheumatic AOSD' patients, exhibiting pre-eminence of joint involvement driven by IL-8 and IFN-γ production, would be at risk of articular destructions, and would preferentially respond to TNF-α blockers.
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Affiliation(s)
- Alexandre Thibault Jacques Maria
- Department of Internal Medicine-Multiorganic Diseases, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, F-34295 Montpellier, France; Inserm, U 844, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, Montpellier F-34295, France
| | - Alain Le Quellec
- Department of Internal Medicine-Multiorganic Diseases, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, F-34295 Montpellier, France
| | - Christian Jorgensen
- Inserm, U 844, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, Montpellier F-34295, France; Clinical Immunology and Osteoarticular Diseases Therapeutic Unit, Lapeyronie Hospital, 191 Avenue du Doyen Gaston Giraud, F-34295 Montpellier, France
| | - Isabelle Touitou
- Inserm, U 844, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, Montpellier F-34295, France; Auto-Inflammatory Diseases Unit, Genetic Laboratory, Arnaud De Villeneuve Hospital, 191 Avenue du Doyen Gaston Giraud, F-34295 Montpellier, France
| | - Sophie Rivière
- Department of Internal Medicine-Multiorganic Diseases, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, F-34295 Montpellier, France
| | - Philippe Guilpain
- Department of Internal Medicine-Multiorganic Diseases, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, F-34295 Montpellier, France; Inserm, U 844, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, Montpellier F-34295, France.
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14
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Bannai E, Yamashita H, Kaneko S, Ueda Y, Ozaki T, Tsuchiya H, Takahashi Y, Kaneko H, Kano T, Mimori A. Successful tocilizumab therapy in seven patients with refractory adult-onset Still's disease. Mod Rheumatol 2014; 26:297-301. [DOI: 10.3109/14397595.2014.899178] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Ei Bannai
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
| | - Hiroyuki Yamashita
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
| | - Shunta Kaneko
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yo Ueda
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
| | - Takashi Ozaki
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
| | - Haruka Tsuchiya
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yuko Takahashi
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
| | - Hiroshi Kaneko
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
| | - Toshikazu Kano
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
| | - Akio Mimori
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
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15
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Gerfaud-Valentin M, Jamilloux Y, Iwaz J, Sève P. Adult-onset Still's disease. Autoimmun Rev 2014; 13:708-22. [PMID: 24657513 DOI: 10.1016/j.autrev.2014.01.058] [Citation(s) in RCA: 345] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 01/02/2014] [Indexed: 12/17/2022]
Abstract
First described in 1971, adult-onset Still's disease (AOSD) is a rare multisystemic disorder considered as a complex (multigenic) autoinflammatory syndrome. A genetic background would confer susceptibility to the development of autoinflammatory reactions to environmental triggers. Macrophage and neutrophil activation is a hallmark of AOSD which can lead to a reactive hemophagocytic lymphohistiocytosis. As in the latter disease, the cytotoxic function of natural killer cells is decreased in patients with active AOSD. IL-18 and IL-1β, two proinflammatory cytokines processed through the inflammasome machinery, are key factors in the pathogenesis of AOSD; they cause IL-6 and Th1 cytokine secretion as well as NK cell dysregulation leading to macrophage activation. The clinico-biological picture of AOSD usually includes high spiking fever with joint symptoms, evanescent skin rash, sore throat, striking neutrophilic leukocytosis, hyperferritinemia with collapsed glycosylated ferritin (<20%), and abnormal liver function tests. According to the clinical presentation of the disease at diagnosis, two AOSD phenotypes may be distinguished: i) a highly symptomatic, systemic and feverish one, which would evolve into a systemic (mono- or polycyclic) pattern; ii) a more indolent one with arthritis in the foreground and poor systemic symptomatology, which would evolve into a chronic articular pattern. Steroid- and methotrexate-refractory AOSD cases benefit now from recent insights into autoinflammatory disorders: anakinra seems to be an efficient, well tolerated, steroid-sparing treatment in systemic patterns; tocilizumab seems efficient in AOSD with active arthritis and systemic symptoms while TNFα-blockers could be interesting in chronic polyarticular refractory AOSD.
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Affiliation(s)
- Mathieu Gerfaud-Valentin
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, Service de médecine interne, F-69004 Lyon, France; Université Lyon I, F-69100 Villeurbanne, France; Université de Lyon, F-69000 Lyon, France
| | - Yvan Jamilloux
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, Service de médecine interne, F-69004 Lyon, France; Inserm U1111, Centre International de Recherche en Infectiologie, F-69365 Lyon, France; Département de Biochimie, Université de Lausanne, 1006 Epalinges, Switzerland
| | - Jean Iwaz
- Université Lyon I, F-69100 Villeurbanne, France; Université de Lyon, F-69000 Lyon, France; Hospices Civils de Lyon, Service de Biostatistique, F-69000 Lyon, France; CNRS UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique Santé, F-69310 Pierre-Bénite, France
| | - Pascal Sève
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, Service de médecine interne, F-69004 Lyon, France; Université Lyon I, F-69100 Villeurbanne, France; Université de Lyon, F-69000 Lyon, France.
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16
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Kiyonaga Y, Maeshima K, Imada C, Haranaka M, Ishii K, Shibata H. Steroid-sparing effects of etanercept in a patient with steroid-dependent adult-onset Still's disease. Intern Med 2014; 53:1209-13. [PMID: 24881751 DOI: 10.2169/internalmedicine.53.1488] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report the case of an 84-year-old man with steroid-dependent adult-onset Still's disease (AOSD) whose daily steroid dose was successfully tapered after etanercept treatment. The corticosteroids worked well initially, and the patient went into remission promptly; however, he suffered a relapse due to steroid tapering. Because treatment with cyclosporine and methotrexate was ineffective, reducing the steroid dose was difficult, and the corticosteroids induced myopathy and diabetes. However, steroid tapering was accomplished in combination with etanercept therapy, and the patient's steroid-induced side effects disappeared. Etanercept should therefore be considered as a steroid-sparing treatment option in patients with steroid-responsive, steroid-dependent AOSD.
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Affiliation(s)
- Yasuhiro Kiyonaga
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Japan
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17
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Reactive haemophagocytic syndrome in a patient with adult-onset Still's disease: beta-lactams as trigger? Infection 2013; 42:227-8. [PMID: 24214126 DOI: 10.1007/s15010-013-0548-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 10/24/2013] [Indexed: 10/26/2022]
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18
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Yanai H, Moriyama S, Hirowatari Y, Kaneko H. Very low density lipoprotein, chylomicron, and lipoprotein (a) are more useful to detect the development of macrophage activation syndrome in adult-onset still's disease as compared with cytokines and triglyceride. Am J Hematol 2013; 88:828-30. [PMID: 23760887 DOI: 10.1002/ajh.23517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 05/30/2013] [Accepted: 06/04/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Hidekatsu Yanai
- Department of Internal Medicine; National Center for Global Health and Medicine Kohnodai Hospital; Chiba; Japan
| | - Sumie Moriyama
- Department of Internal Medicine; National Center for Global Health and Medicine Kohnodai Hospital; Chiba; Japan
| | | | - Hiroshi Kaneko
- Department of Rheumatology; National Center for Global Health and Medicine Kohnodai Hospital; Chiba; Japan
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19
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Demyelinating encephalopathy in adult onset Still's disease: case report and review of the literatures. Clin Neurol Neurosurg 2013; 115:2213-6. [PMID: 23972587 DOI: 10.1016/j.clineuro.2013.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 06/16/2013] [Indexed: 11/24/2022]
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20
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Therapeutic response of patients with adult Still's disease to biologic agents: multicenter results in Japan. Mod Rheumatol 2011; 22:712-9. [PMID: 22160845 DOI: 10.1007/s10165-011-0569-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 11/17/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVE The efficacy of biologics in treating adult Still's disease (ASD) is suggested, but the information is still lacking and the validation is insufficient. To determine the efficacy of several biologic agents in refractory ASD in Japan, a multicenter survey was performed. METHOD Clinical data on 16 ASD patients who had been treated with at least 1 of the biological agents (total 24 occasions) were collected retrospectively. RESULTS Infliximab was used in 9 cases, etanercept in 4, and tocilizumab in 11. Half of the patients that had been treated initially with infliximab or etanercept were changed to another biologics. Tocilizumab was effective in cases switched from another 2 drugs. Tocilizumab showed efficacy in treating both systemic and arthritic symptoms and showed apparent steroid-sparing effect and the highest continuation rate. CONCLUSION Tocilizumab may be a promising biologic agent in refractory ASD.
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21
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Benefit and a possible risk of tocilizumab therapy for adult-onset Still's disease accompanied by macrophage-activation syndrome. Mod Rheumatol 2010; 21:92-6. [PMID: 20737186 DOI: 10.1007/s10165-010-0348-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Accepted: 07/29/2010] [Indexed: 10/19/2022]
Abstract
We report a 57-year-old female case of intractable adult-onset Still's disease (AOSD). Initial high-dose prednisolone therapy was ineffective, and macrophage-activation syndrome (MAS) manifested after one session of additional tocilizumab therapy. After successful treatment for MAS with lipo-dexamethasone and cyclosporin, tocilizumab therapy aided in the rapid reduction of the therapeutic steroid dose. Tocilizumab may be useful for maintenance therapy for AOSD, although its efficacy is unclear for the highly active phase of the disease.
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22
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Priori R, Colafrancesco S, Gattamelata A, Di Franco M, Di Tondo U, Valesini G. Adult-onset Still disease: a rare disorder with a potentially fatal outcome. AUTOIMMUNITY HIGHLIGHTS 2010; 1:53-9. [PMID: 26000108 PMCID: PMC4389061 DOI: 10.1007/s13317-010-0009-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 03/04/2010] [Indexed: 12/04/2022]
Abstract
Purpose The aim of this study was to assess the clinical and laboratory features of a cohort of Italian patients with adult-onset Still disease (AOSD) with particular attention on possible life-threatening complications. Methods The clinical charts of 41 consecutive Italian patients with AOSD referred to our rheumatological department over the last 10 years were retrospectively examined. Data regarding clinical manifestations, laboratory features and complications were collected and compared with those reported in literature. Results The most frequent manifestations were: fever (90.2%), arthralgias (80.4%), skin rash (75.6%), sore throat (53.6%), arthritis (51.2%), lymphadenopathy (48.7%), hepatosplenomegaly (41.4%), myalgia (21.9%), fatigue (12%), diarrhoea and vomiting (9.7%), pleural effusion (9.7%), pericardial effusion (4.8%) and abdominal pain (2.4%). In two patients whose cases are described in detail; the course of the disease was complicated by disseminated intravascular coagulopathy, in one patient with a fatal outcome. ESR, CRP and leucocyte count mean values were 69.41 mm/h, 69.05 mg/l and 18,798.5 cell/mm3 (neutrophils 84.64%), respectively. Serum ferritin levels were increased in 48.7% of patients while transaminases were elevated in 42.6% of patients (71% considering only patients in an active phase of disease). Conclusion The results of this study are in line with those reported for other cohorts of patients. Even if the prognosis of AOSD is considered favourable, the present study indicates that the disease is a troubling condition needing prompt intervention. Occasionally, AOSD may rapidly worsen with life-threatening events.
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Affiliation(s)
- Roberta Priori
- UOC Reumatologia, Policlinico Umberto I, Università La Sapienza, Viale del Policlinico, 00161 Rome, Italy
| | - Serena Colafrancesco
- UOC Reumatologia, Policlinico Umberto I, Università La Sapienza, Viale del Policlinico, 00161 Rome, Italy
| | - Angelica Gattamelata
- UOC Reumatologia, Policlinico Umberto I, Università La Sapienza, Viale del Policlinico, 00161 Rome, Italy
| | - Manuela Di Franco
- UOC Reumatologia, Policlinico Umberto I, Università La Sapienza, Viale del Policlinico, 00161 Rome, Italy
| | - Ugo Di Tondo
- UOC Reumatologia, Policlinico Umberto I, Università La Sapienza, Viale del Policlinico, 00161 Rome, Italy
| | - Guido Valesini
- UOC Reumatologia, Policlinico Umberto I, Università La Sapienza, Viale del Policlinico, 00161 Rome, Italy
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23
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El-Bitar MK, Muwakkit SA, Hourani R, Abboud MR, Saab R, Dabbagh O. Severe cerebral vaso-occlusive disease in macrophage activation syndrome. Pediatr Neurol 2010; 42:283-6. [PMID: 20304334 DOI: 10.1016/j.pediatrneurol.2009.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Revised: 09/08/2009] [Accepted: 09/09/2009] [Indexed: 11/30/2022]
Abstract
A 14-year-old girl was diagnosed with macrophage activation syndrome, based on clinical presentation, laboratory tests, and bone marrow aspirate findings. She developed severe central nervous system involvement in the form of seizure disorder and severe diffuse occlusive cerebral vasculopathy, with extensive collateral circulation consistent with moyamoya disease. To our knowledge, this description is the first of these findings in association with macrophage activation syndrome.
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Affiliation(s)
- Mohamad K El-Bitar
- Division of Pediatric Neurology and Pediatric Epilepsy Program, Department of Pediatrics, American University of Beirut Medical Center, 2020l Beirut, Lebanon
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24
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Hot A, Toh ML, Coppéré B, Perard L, Girard Madoux MH, Mausservey C, Desmurs-Clavel H, Ffrench M, Ninet J. Reactive hemophagocytic syndrome in adult-onset Still disease: clinical features and long-term outcome: a case-control study of 8 patients. Medicine (Baltimore) 2010; 89:37-46. [PMID: 20075703 DOI: 10.1097/md.0b013e3181caf100] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Reactive hemophagocytic syndrome (RHS) is a rare, life-threatening, and little-known complication of rheumatic diseases. This disorder is characterized by fever, pancytopenia, liver failure, coagulopathy, and neurologic symptoms. RHS may develop in patents who have lymphoma, organ transplantation, serious infection, and rheumatic diseases, most notably systemic lupus erythematosus and adult-onset Still disease (AOSD). Observations of specific cases of RHS in AOSD remain rare, and the significance of this syndrome during the course of AOSD remains unknown. We retrospectively studied 16 episodes of AOSD-associated RHS in 8 patients. To determine whether RHS is associated with a particular phenotype of AOSD, we conducted a case-control study from the cohort of AOSD patients seen during the same period. The estimated frequency of RHS in AOSD patients from our cohort was 15.3% (8/52). The median age at RHS diagnosis was 44.5 years. We collected clinical and laboratory data. RHS was the first manifestation of AOSD in 7 cases. The main symptoms were fever (n = 8), salmon rash (n = 6), arthralgia (n = 7), lymphadenopathy (n = 6), and shock (n = 4). Serum ferritin concentration was consistently elevated (>1000 microg/L in 8 cases), and the level of glycosylated ferritin was low in all cases (<5% in 7 cases, 15% in 1 case). Six patients presented with coagulopathy; hypertriglyceridemia was found in 6 cases. Admission to the intensive care unit was required in 4 cases. Treatment included corticosteroids (n = 8) and intravenous immunoglobulin (n = 6), cyclophosphamide in 2 cases, infliximab in the same 2 cases, and cyclosporine in 1 case. With a follow-up ranging from 2 to 15 years, the patients were in remission with prednisone plus methotrexate (n = 4), prednisone plus infliximab (n = 2), and low-dose prednisone alone (n = 2). We compared the 8 patients included in this study with 44 control patients with AOSD without RHS. Low haptoglobin levels, very high ferritin levels (>10,000 microg/L), and a normal or low neutrophil count seem to be predictive factors of the occurrence of RHS in AOSD.
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Affiliation(s)
- Arnaud Hot
- From Service de Médecine Interne (AH, BC, LP, MHGM, CM, HDC, JN); and Unité Mixte Inflammation et Immunité (AH, MLT), HCL-Biomérieux; Hôpital Edouard Herriot, Lyon; Université Claude Bernard Lyon I (AH, CM, JN), Lyon; and Service de Cytologie et Histopathologie Médullaire (MF), Centre Hospitalier Lyon SUD, Pierre Bénite, France
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