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Serhan HA, Abuawwad MT, Taha MJJ, Hassan AK, Abu-Ismail L, Delsoz M, Alrawashdeh HM, Alkorbi HA, Moushmoush O, Elnahry AG. Purtscher's and Purtscher-like retinopathy etiology, features, management, and outcomes: A summative systematic review of 168 cases. PLoS One 2024; 19:e0306473. [PMID: 39240905 PMCID: PMC11379300 DOI: 10.1371/journal.pone.0306473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/18/2024] [Indexed: 09/08/2024] Open
Abstract
BACKGROUND To describe Purtscher's and Purtscher-like retinopathy clinical features, etiologies, management options, and visual outcomes. METHODS Our protocol was registered on PROSPERO [registration number: CRD42023406843]. Seven online databases were searched: PubMed, Scopus, Medline, ScienceDirect, CENTRAL, clinicaltrials.gov, and Google Scholar. Original articles were included if they reported at least one subject diagnosed with Purtscher's or Purtscher-like retinopathy. The primary outcome is to describe the clinical features of Purtscher and Purtscher-like retinopathies, including etiologies, results of related investigations, management lines, and visual outcomes. All analyses were conducted with the use of Statistical Package for Social Sciences (SPSS) version 27 (IBM SPSS Corp, SPSS Statistics ver. 26, USA) and Cochrane's RevMan software. The methodological quality of included studies was assessed using the NIH quality assessment tools. RESULTS A total of 114 articles were included, describing 168 cases of Purtscher's and Purtscher-like retinopathy. Patients were evenly distributed between males (50.89%) and females (49.11%). Average age of patients was 34.62 years old. Trauma was the leading cause of retinopathy, being reported in 39.88% of our patients, followed by systemic lupus erythematosus (SLE) (13.1%) and acute pancreatitis (11.9%). Bilateral symptoms were reported in 57.7% of patients with centrally blurred vision being the most complained symptom (OS: 34.32% and OD: 18%). 75% of patients elicited bilateral retinal findings. Cotton-wool spots were of highest prevalence (58%). Purtscher flecken was seen in 53% of patients. Macular edema was seen in 13% of patients. Overall, patients had a favorable prognosis (53%). CONCLUSION Purtscher's and Purtscher-like retinopathies are rare sight-threatening retinopathies that develop most commonly following trauma or other systemic diseases as SLE and acute pancreatitis. Little data is available regarding these conditions, and available data is of low quality. Patients develop bilateral disease in approximately 50% of cases, and several retinal findings are observed, with no specific tendency. Most observed signs are cotton-wool spots in around 55% of patients and Purtscher flecken in 51% of patients. Patients spontaneously recovered, although data is not conclusive. No clear prognostic value of etiological factors is identified, and further research is required in this regard.
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Affiliation(s)
| | | | | | - Amr K Hassan
- Gavin Herbert Eye Institute, University of California, Irvine, Irvine, California, United States of America
| | - Luai Abu-Ismail
- Department of Ophthalmology, Islamic Hospital, Amman, Jordan
| | - Mohammad Delsoz
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, United States of America
| | | | | | - Obadah Moushmoush
- Department of Ophthalmology, MedStar Georgetown University Hospital, Washington, D.C., United States of America
| | - Ayman G Elnahry
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States of America
- Department of Ophthalmology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Ananthaneni A, Shimkus G, Weis F, Adu-Dapaah E, Lakra R, Ramadas P, Hayat S. Adult-onset Still's disease with concurrent thrombotic microangiopathy: Observations from pooled analysis for an uncommon finding. Eur J Haematol 2024; 112:484-492. [PMID: 37997494 DOI: 10.1111/ejh.14142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder that is characterized by quotidian fevers, arthritis, and an evanescent rash. Occurrence of concurrent thrombotic microangiopathy (TMA) in AOSD is rare. The treatment aspects of TMA in AOSD are actively being debated. METHODS Medline search using MeSH terms and snowballing yielded a total of 29 articles with co-occurrence of AOSD and thrombotic thrombocytopenic purpura (TTP) including our own. Pooled data were synthesized for descriptive analysis. RESULTS Median age was 35 years with a majority of females (68.96%). A majority of these studies/patients were either Asian (34.48%) or Caucasian (31.03%). Concurrent TMA at the time of AOSD diagnosis was seen in 65.51% patients. Only 3/29 patients had ADAMTS13 level less than 10%, consistent with TTP and 3/29 were diagnosed with hemolytic uremic syndrome (HUS). The remainder were diagnosed clinically. Complication rate was high, and 15/29 (51.72%) patients died or had permanent neurological/renal/vision/gangrenous complications. Median and mean ferritin peak was observed to be higher (7458 and 12 349, respectively) in patients who either died/had partial remission, compared to those who had complete response (3257 and 10 899, respectively), p = .829. CONCLUSIONS A majority of patients with AOSD-associated TMA either died or had permanent complications. TMA was diagnosed alongside AOSD in 65% patients, while the rest developed TMA during the course of their disease. Blurred vision may precede TMA and could help risk-stratify high-risk AOSD patients clinically. Glycosylated ferritin remains low several weeks to months after disease remission and may be used to monitor severity of disease process. Further studies are necessary to confirm the existing vascular endothelial growth factor hypothesis in AOSD-associated TMA.
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Affiliation(s)
- Anil Ananthaneni
- Division of Hematology & Oncology, Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Gaelen Shimkus
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Francesca Weis
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Eunice Adu-Dapaah
- Division of Rheumatology, Department of Internal Medicine, University of California, Los Angeles, California, USA
| | - Rachaita Lakra
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Poornima Ramadas
- Division of Hematology & Oncology, Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Samina Hayat
- Division of Rheumatology, Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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Fonollosa A, Carreño E, Vitale A, Jindal AK, Ramanan AV, Pelegrín L, Santos-Zorrozua B, Gómez-Caverzaschi V, Cantarini L, Fabiani C, Hernández-Rodríguez J. Update on ocular manifestations of the main monogenic and polygenic autoinflammatory diseases. FRONTIERS IN OPHTHALMOLOGY 2024; 4:1337329. [PMID: 38984133 PMCID: PMC11182141 DOI: 10.3389/fopht.2024.1337329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/30/2024] [Indexed: 07/11/2024]
Abstract
Autoinflammatory diseases include disorders with a genetic cause and also complex syndromes associated to polygenic or multifactorial factors. Eye involvement is present in many of them, with different extent and severity. The present review covers ophthalmological lesions in the most prevalent monogenic autoinflammatory diseases, including FMF (familial Mediterranean fever), TRAPS (TNF receptor-associated periodic syndrome), CAPS (cryopyrin-associated periodic syndromes), Blau syndrome, DADA2 (deficiency of adenosine deaminase 2), DITRA (deficiency of the interleukin-36 receptor antagonist), other monogenic disorders, including several ubiquitinopathies, interferonopathies, and the recently described ROSAH (retinal dystrophy, optic nerve edema, splenomegaly, anhidrosis, and headache) syndrome, and VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome. Among polygenic autoinflammatory diseases, ocular manifestations have been reviewed in Behçet's disease, PFAPA (periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis) syndrome, Still's disease and autoinflammatory bone diseases, which encompass CRMO (chronic recurrent multifocal osteomyelitis) and SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome.
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Affiliation(s)
- Alex Fonollosa
- Department of Ophthalmology, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Barakaldo, Spain
- Department of Retina, Instituto Oftalmológico Bilbao, Bilbao, Spain
| | - Ester Carreño
- Department of Ophthalmology, Rey Juan Carlos University Hospital, Madrid, Spain
- Department of Ophthalmology, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Antonio Vitale
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Siena, Italy
| | - Ankur K Jindal
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children and Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Laura Pelegrín
- Department of Ophthalmology, Institut Clínic d'Oftalmologia (ICOF), Hospital Clinic de Barcelona, University of Barcelona, Institut de Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Borja Santos-Zorrozua
- Department of Biostatistics, Biocruces Bizkaia Health Research Institute, Bilbao, Spain
| | - Verónica Gómez-Caverzaschi
- Autoinflammatory Diseases Clinical Unit, Department of Autoimmune Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Barcelona, Spain
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Siena, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Siena, Italy
| | - José Hernández-Rodríguez
- Autoinflammatory Diseases Clinical Unit, Department of Autoimmune Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Barcelona, Spain
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4
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Dillemans L, Bekhuis Y, Betrains A, Yu K, van Hemelen M, Pörtner N, De Somer L, Matthys P, Breckpot J, Tousseyn T, Peetermans M, Proost P, Wouters C, Vanderschueren S. Biallelic mutations in the CFHR genes underlying atypical hemolytic uremic syndrome in a patient with catastrophic adult-onset Still's disease and recurrent macrophage activation syndrome: A case report. Clin Immunol 2023; 257:109815. [PMID: 37898413 DOI: 10.1016/j.clim.2023.109815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 10/02/2023] [Accepted: 10/24/2023] [Indexed: 10/30/2023]
Abstract
We report the fatal case of a 20-year-old woman with refractory adult-onset Still's disease (AOSD) accompanied by fulminant macrophage activation syndrome (MAS) and atypical hemolytic uremic syndrome (aHUS). Anakinra and tocilizumab temporarily controlled AOSD. In 2021, she presented to ICU with generalized tonic-clonic seizure, lymphocytic aseptic meningitis, and acute kidney injury. Despite hemodialysis and methylprednisolone, she developed another seizure, MAS, and disseminated intravascular coagulation (DIC). Following brief control, MAS flares -reflected by increased plasma CXCL9 and CXCL10- re-emerged and were controlled through dexamethasone, etoposide, cyclosporin and tofacitinib. No mutations were detected in haemophagocytic lymphohistiocytosis (HLH)-associated genes, nor in genes associated with periodic fever syndromes. Post-mortem genetic testing revealed loss-of-function biallelic deletions in complement factor H-related proteins (CFHR) genes, predisposing aHUS. This case underscores the importance of prompt genetic assessment of complement-encoding alleles, in addition to HLH-related genes, in patients with severe AOSD with recurrent MAS and features of thrombotic microangiopathy (TMA).
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Affiliation(s)
- Luna Dillemans
- Laboratory of Molecular Immunology, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Belgium
| | - Youri Bekhuis
- Laboratory of Cardiology, Department of Cardiovascular Sciences, KU Leuven, Belgium; Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium
| | - Albrecht Betrains
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Belgium; European Reference Network for Immunodeficiency, Autoinflammatory, Autoimmune and Pediatric Rheumatic disease (ERN-RITA), University Hospitals Leuven, Belgium
| | - Karen Yu
- Laboratory of Molecular Immunology, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Belgium
| | - Maarten van Hemelen
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Belgium
| | - Noëmie Pörtner
- Laboratory of Molecular Immunology, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Belgium
| | - Lien De Somer
- European Reference Network for Immunodeficiency, Autoinflammatory, Autoimmune and Pediatric Rheumatic disease (ERN-RITA), University Hospitals Leuven, Belgium; Laboratory of Immunobiology, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Belgium; Department of Pediatric Rheumatology, University Hospitals Leuven, Belgium
| | - Patrick Matthys
- Laboratory of Immunobiology, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Belgium
| | | | - Thomas Tousseyn
- Translational Cell and Tissue Research, Department of Imaging and Pathology, KU Leuven, Belgium
| | - Marijke Peetermans
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Belgium; Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Belgium
| | - Paul Proost
- Laboratory of Molecular Immunology, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Belgium.
| | - Carine Wouters
- European Reference Network for Immunodeficiency, Autoinflammatory, Autoimmune and Pediatric Rheumatic disease (ERN-RITA), University Hospitals Leuven, Belgium; Laboratory of Immunobiology, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Belgium
| | - Steven Vanderschueren
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Belgium; European Reference Network for Immunodeficiency, Autoinflammatory, Autoimmune and Pediatric Rheumatic disease (ERN-RITA), University Hospitals Leuven, Belgium
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5
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Ben Salah R, Bouattour Y, Turki C, Frikha F, Bahloul Z. Coexistence of thrombotic thrombocytopenic purpura and adult-onset Still's disease. Clin Case Rep 2022; 10:e05474. [PMID: 35228881 PMCID: PMC8864579 DOI: 10.1002/ccr3.5474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 01/07/2022] [Accepted: 02/07/2022] [Indexed: 01/05/2023] Open
Abstract
The association of Thrombotic thrombocytopenic purpura (TTP) and adult-onset Still's disease (AOSD) is very uncommon. Hereby, we present a case of TTP occurring in patient with a known AOSD and the successful outcome after plasma exchanges.
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Affiliation(s)
- Raida Ben Salah
- Department of internal medicineHediChakerUniversity HospitalSfaxTunisia
| | - Yosra Bouattour
- Department of internal medicineHediChakerUniversity HospitalSfaxTunisia
| | - Chourouk Turki
- Department of internal medicineHediChakerUniversity HospitalSfaxTunisia
| | - Faten Frikha
- Department of internal medicineHediChakerUniversity HospitalSfaxTunisia
| | - Zouhir Bahloul
- Department of internal medicineHediChakerUniversity HospitalSfaxTunisia
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6
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Akiyama K, Iwasaki Y, Tanaka R. Severe Adult Still's Disease Complicated by Purtscher-Like Retinopathy Treated with Intravenous Pulse Methylprednisolone and Tocilizumab. Case Rep Ophthalmol 2021; 12:531-537. [PMID: 34248587 PMCID: PMC8255712 DOI: 10.1159/000516851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/21/2021] [Indexed: 12/21/2022] Open
Abstract
Adult Still's disease (ASD) is a rare systemic inflammatory disorder in which ocular manifestations have rarely been described. We report a 29-year-old Japanese woman with a rare case of refractory ASD complicated by Purtscher-like retinopathy. She was diagnosed with ASD and started on a high dose of oral prednisolone. Two days after the initiation of the treatment, she presented with blurred vision in the left eye, and the funduscopic examination revealed bilateral Purtscher-like retinopathy. Despite treatment with high-dose oral prednisolone for 2 weeks, she developed macrophage activation syndrome. Considering the severity of ASD, intravenous pulse methylprednisolone therapy and tocilizumab injection were administered. Although all the laboratory data and Purtscher-like retinopathy gradually improved, nerve fiber layer defect (NFLD) in both eyes appeared and visual field defect remained corresponding to the NFLD. In conclusion, Purtscher-like retinopathy might be useful as a poor prognostic factor of ASD, which needs appropriate systemic immunosuppressive treatment. Early detection and long-term follow-up of Purtscher-like retinopathy is important because it has the possibility of developing permanent visual field defect.
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Affiliation(s)
- Kaho Akiyama
- Department of Ophthalmology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yukiko Iwasaki
- Department of Allergy and Rheumatology, The University of Tokyo Hospital, Tokyo, Japan
| | - Rie Tanaka
- Department of Ophthalmology, The University of Tokyo Hospital, Tokyo, Japan
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7
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Kato R, Ikeuchi T, Tomita K, Yamasaki A. Adult-onset Still's disease with concurrent thrombotic thrombocytopenic purpura: case report and literature review. BMJ Case Rep 2020; 13:13/9/e235786. [PMID: 32988976 DOI: 10.1136/bcr-2020-235786] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is rare complication resulting from adult-onset Still's disease (AOSD). We report the case of a 69-year-old Japanese man who initially presented with fever and joint pain and was diagnosed as having concurrent AOSD with TTP 1 month later. He had extremely high ferritin levels (32 696 ng/mL). He initially responded to plasma exchange but subsequently died of septic shock. AOSD accompanied by extremely high ferritin levels might be considered a sign of concurrent TTP.
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Affiliation(s)
- Ryohei Kato
- Division of Respiratory Medicine and Rheumatology, Department of Multidisclplinary Internal Medicine, Faculty of Medicine, Tottori University Hospital, Yonago, Tottori, Japan
| | - Tomoyuki Ikeuchi
- Department of Respiratory Medicine, Yonago Medical Centre, National Hospital Organisation Yonago Medical Center, Yonago, Tottori, Japan
| | - Katsuyuki Tomita
- Department of Respiratory Medicine, Yonago Medical Centre, National Hospital Organisation Yonago Medical Center, Yonago, Tottori, Japan
| | - Akira Yamasaki
- Division of Respiratory Medicine and Rheumatology, Department of Multidisclplinary Internal Medicine, Faculty of Medicine, Tottori University Hospital, Yonago, Tottori, Japan
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Tang AA, Lin AL. Purtscher-like retinopathy in adult-onset Still's disease, complicated by treatment-related central serous chorioretinopathy. Am J Ophthalmol Case Rep 2020; 18:100631. [PMID: 32140617 PMCID: PMC7052061 DOI: 10.1016/j.ajoc.2020.100631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 11/18/2019] [Accepted: 02/21/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose We describe a case of Purtscher-like retinopathy associated with adult-onset Still's disease, complicated by the development of central serous chorioretinopathy secondary to high dose corticosteroids. Observations A 53 year old female diagnosed with adult-onset Still's disease (AOSD) presented to us with findings consistent with Purtscher-like retinopathy in both eyes, with 20/70 visual acuity in the right eye and 20/20 visual acuity in the left eye. She was initiated on high dose corticosteroids by her rheumatologists for her AOSD. A month later, her vision worsened significantly to counting fingers at 3 feet in the right eye and 20/60 visual acuity in the left. Her examination revealed serous macular detachments involving her fovea consistent with central serous chorioretinopathy secondary to exogenous steroids. After discussion with her rheumatologists, she was tapered off her steroids quickly and bridged to steroid sparing agents, with subsequent resolution of her serous macular detachments and improvement of vision back to baseline. Conclusion and Importance The association of Purtscher-like retinopathy and AOSD is important from a multidisciplinary standpoint due to the possibility of life-threatening systemic thrombotic microangiopathy. In addition, patients undergoing treatment for AOSD with exogenous corticosteroids may develop central serous retinopathy with vision loss, and may require quick transitioning to steroid-sparing agents if focal laser is not feasible.
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Affiliation(s)
| | - Albert L. Lin
- Corresponding author. Department of Ophthalmology, 2500 N. State Street, Jackson, MS, 39216, USA.
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Escoda T, Seguier J, Swiader L, Briantais A, Sampo M, Harlé JR, Durand JM. [Purtscher-like retinopathy associated with adult onset still disease: Case report and review of the literature]. Rev Med Interne 2020; 41:279-283. [PMID: 31983549 DOI: 10.1016/j.revmed.2019.12.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 11/25/2019] [Accepted: 12/22/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Putscher-like retinopathy is a retinal disease that is similar to the syndrome initially described in 1910 by Purtscher, but occurring in a non-traumatic context. CASE REPORT We describe a case of acute, Putscher-like retinopathy in a 48-year-old woman experiencing adult onset Still's disease. The diagnosis was based on fundus examination and fluorescein angiography. Based on a review of the literature, we discuss the current available data on the pathophysiology of this syndrome and its prognostic significance. The treatment remains controversial. CONCLUSION When visual functional signs appear during adult Still's disease, it is necessary to evoke Putscher-like retinopathy, and to ask for an ophthalmological expertise.
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Affiliation(s)
- T Escoda
- Service de médecine Interne, hôpital La Timone, Assistance publique, hôpitaux de Marseille, Aix-Marseille université, 13005 Marseille, France.
| | - J Seguier
- Service de médecine Interne, hôpital La Timone, Assistance publique, hôpitaux de Marseille, Aix-Marseille université, 13005 Marseille, France.
| | - L Swiader
- Service de médecine Interne, hôpital La Timone, Assistance publique, hôpitaux de Marseille, Aix-Marseille université, 13005 Marseille, France.
| | - A Briantais
- Service de médecine Interne, hôpital La Timone, Assistance publique, hôpitaux de Marseille, Aix-Marseille université, 13005 Marseille, France.
| | - M Sampo
- Service d'ophtalmologie, hôpital La Timone, Assistance publique, hôpitaux de Marseille, Aix-Marseille université, 13005 Marseille, France.
| | - J R Harlé
- Service de médecine Interne, hôpital La Timone, Assistance publique, hôpitaux de Marseille, Aix-Marseille université, 13005 Marseille, France.
| | - J M Durand
- Service de médecine Interne, hôpital La Timone, Assistance publique, hôpitaux de Marseille, Aix-Marseille université, 13005 Marseille, France.
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Rafat C, Luque Y. Thrombotic microangiopathy in adult-onset Still's disease: the story is just beginning. Expert Rev Clin Immunol 2019; 15:1123-1124. [PMID: 31650884 DOI: 10.1080/1744666x.2019.1682892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Cédric Rafat
- Urgences Néphrologiques et Transplantation Rénale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Tenon, Paris, France
| | - Yosu Luque
- Urgences Néphrologiques et Transplantation Rénale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Tenon, Paris, France.,Sorbonne Université, Inserm, Paris, France
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Abstract
PURPOSE To describe clinical, laboratory, and funduscopic data of a patient presenting with newly diagnosed adult-onset Still disease and Purtscher-like retinopathy. METHODS Observational case report. PATIENT A 43-year-old man presented with a 3-week history of daily high-spiking fever, diffuse arthralgia and myalgia, sore throat, and a transient nonpruritic maculopapular rash. Two weeks from the onset of his illness, he developed a gradual decrease in visual acuity in both eyes. Fundoscopic examination showed multiple areas of retinal whitening, discrete superficial retinal hemorrhages, and few characteristic Purtscher flecken in the left eye. RESULTS The patient was diagnosed with adult-onset Still disease. We used high-dose corticosteroid therapy with complete resolution of adult-onset Still disease, but it was ineffective for recovery of vision. CONCLUSION Clinicians should be aware of Purtscher-like retinopathy as a severe ophthalmic complication of adult-onset Still disease.
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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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Ang LJPS, Chang BCM. Purtscher-like retinopathy - A rare complication of acute myocardial infarction and a review of the literature. Saudi J Ophthalmol 2017; 31:250-256. [PMID: 29234228 PMCID: PMC5717495 DOI: 10.1016/j.sjopt.2017.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 05/10/2017] [Accepted: 05/13/2017] [Indexed: 11/16/2022] Open
Abstract
Purtscher-like retinopathy is an uncommon condition with features similar to Purtscher retinopathy but have non-traumatic causes. Several pathogenic mechanisms have been put forth with differing views on treatment options. We describe for the first time, a case of Purtscher-like retinopathy which developed following a myocardial infarct and a transient ischemic attack. We present a review of the literature on this condition, describing the various clinical presentations, investigation findings, treatment options and prognosis.
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Xia D, Chen X, Zhou Q, Xiao S, Yu Y, Wang Y, Du G, Huang H, Zhang W, Chen Y. Efficacy of Purtscher's Retinopathy Treatments: A Systematic Review. Curr Eye Res 2017; 42:908-917. [PMID: 28139150 DOI: 10.1080/02713683.2016.1255335] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The aim of this review is to evaluate the efficacy of available Purtscher's Retinopathy treatments. MATERIALS AND METHODS In order to collect single-case reports, electronic searches were conducted in several databases including PubMed, Embase, Web of Science, China National Knowledge Infrastructure, SinoMed, VIP, and WanFang in the Electronic Theses and Dissertations Center. In VIP and Wanfang, we also traced the references of included articles. Risk of bias was evaluated using a tool adapted from the Cochrane Risk of Bias Tool. Statistical analysis was done in SPSS19.0. Evidence was evaluated and graded with GRADE system. RESULTS In total, 76 studies were included involving 88 cases and 139 eyes. Serious bias existed in 90% of the included studies. Current treatments for Purtscher's retinopathy included glucocorticoid therapy (63.29%), traditional Chinese medicine therapy (10.13%), glucocorticoid integrative medicine therapy (7.60%), and integrative medicine therapy (6.33%). Patients' eyesight with (56.83%) or without (43.17%) treatment both improved in the follow-up within 1-3 months, 4-6 months, and more than 6 months; however, conditions without treatment became better compared to the treatment groups in after 4-6 months and more than 6 months. All results were "very low" in the GRADE system. None of the studies reported adverse reactions in any patient. CONCLUSIONS Both treatment and no treatment improve vision in Purtscher's retinopathy patients, but the difference between no treatment and glucocorticoid therapy had no statistical significance. The evidence quality for this conclusion was "very low" and had large bias. Further research is required to understand the safety of Purtscher's retinopathy treatment.
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Affiliation(s)
- Duosheng Xia
- a The First People's Hospital of Lanzhou , Lanzhou , China
| | - Xiaomei Chen
- a The First People's Hospital of Lanzhou , Lanzhou , China
| | - Qi Zhou
- b School of Basic Medicine of Lanzhou University , Lanzhou , China
| | - Shujun Xiao
- b School of Basic Medicine of Lanzhou University , Lanzhou , China
| | - Yang Yu
- b School of Basic Medicine of Lanzhou University , Lanzhou , China
| | - Yadong Wang
- c The Second Hospital of Lanzhou University , Lanzhou , China
| | - Gang Du
- c The Second Hospital of Lanzhou University , Lanzhou , China
| | - Haixiang Huang
- c The Second Hospital of Lanzhou University , Lanzhou , China
| | - Wenfang Zhang
- c The Second Hospital of Lanzhou University , Lanzhou , China
| | - Yaolong Chen
- d Evidence Based Medicine Center of Lanzhou University/Chinese GRADE Center , Lanzhou , China
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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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16
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Diagnostic and Therapeutic Challenges. Retina 2015; 35:1480-3. [PMID: 25635573 DOI: 10.1097/iae.0000000000000364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Masuyama A, Kobayashi H, Kobayashi Y, Yokoe I, Sugimura Y, Maniwa K, Sato H, Ishida T, Hatanaka Y. A case of adult-onset Still’s disease complicated by thrombotic thrombocytopenic purpura with retinal microangiopathy and rapidly fatal cerebral edema. Mod Rheumatol 2014. [DOI: 10.3109/s10165-012-0650-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sayarlioglu M, Sayarlioglu H, Ozkaya M, Balakan O, Ucar MA. Thrombotic thrombocytopenic purpura–hemolytic uremic syndrome and adult onset Still’s disease: case report and review of the literature. Mod Rheumatol 2014. [DOI: 10.3109/s10165-008-0061-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Mehmet Sayarlioglu
- Department of Internal Medicine, Division of Rheumatology, Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey
| | - Hayriye Sayarlioglu
- Department of Internal Medicine, Division of Nephrology, Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey
| | - Mesut Ozkaya
- Department of Internal Medicine, Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey
| | - Ozan Balakan
- Department of Internal Medicine, Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey
| | - Mehmet Ali Ucar
- Department of Internal Medicine, Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey
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Carron PL, Cartier JC, Truche AS, Brunelle C, Cartier J, Malvezzi P, Ponard D. Complement alternative pathway activation in the course of thrombotic microangiopathy associated with adult-onset Still's disease. Transfus Apher Sci 2013; 49:533-4. [PMID: 23562215 DOI: 10.1016/j.transci.2013.02.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 02/28/2013] [Indexed: 11/18/2022]
Abstract
Atypical haemolytic uraemic syndrome is a rare disease associated which genetic or acquired factors those cause defective regulation of the alternative complement pathway. We report the case of a 46-year-old woman who presented with thrombotic microangiopathy coinciding with a monocyclic evolution of adult-onset Still's disease. Low C3 with decreased FB concentration, associated with normal C4 was present until the thrombotic microangiopathy's resolution, indicative of an excessive production of alternative C3 convertase. She responded to plasma exchange. This observation reinforces the hypothesis for a common pathway in the pathogenesis for both of the diseases, and suggests alternative complement pathway mediation.
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Affiliation(s)
- Pierre-Louis Carron
- Service de Néphrologie Dialyse et Transplantation, Centre Hospitalier Universitaire, Grenoble, France.
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Miguel AIM, Henriques F, Azevedo LFR, Loureiro AJR, Maberley DAL. Systematic review of Purtscher's and Purtscher-like retinopathies. Eye (Lond) 2013; 27:1-13. [PMID: 23174749 PMCID: PMC3545384 DOI: 10.1038/eye.2012.222] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 10/02/2012] [Indexed: 11/08/2022] Open
Abstract
PURPOSE (1) To describe the clinical characteristics of Purtscher and Purtscher-like retinopathies, including etiologies, fundoscopic signs, results of complementary investigation, treatments, and outcomes. (2) To compare visual acuity (VA) of patients receiving corticosteroids for PuR compared with observation. METHODS Systematic review of several databases (1980-2010): Medline, EMBASE, ISI, EBSCO, Science Direct and Google Scholar. Study selection criteria included: (A) Studies of PuR with ophthalmology assessments; (B) ≥3 of 5 diagnostic criteria of PuR; (C) Quantified VA at presentation. For quantitative assessment (purpose 2), we selected only studies that reported whether corticosteroids were administered, and with vision assessments after at least 1 month. RESULTS (1) From 670 studies initially found, 40 were included (68 cases, 110 eyes): 1 prospective, 5 case series, and 34 case reports. Mean VA at presentation was 1.3 logMAR (logarithm of the minimum angle of resolution) (<20/200; range: 20/20-light perception). Purtscher flecken were underreported. Trauma and acute pancreatitis were the most frequent etiologies. There were six deaths, all with systemic associations. (2) There was no statistically significant difference between VA improvement for patients treated with corticosteroids compared with observation. Visual prognostic factors identified included etiology (pancreatitis and trauma were associated with higher probability of visual improvement) and male gender. CONCLUSION Due to limitations of case reports and series, the presented data are only useful as broad characterizations of the clinical course of PuR. Further studies, possibly including trials to assess the effectiveness of corticosteroids use, and larger prospective cohort studies, are necessary, but may not be feasible to conduct.
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Affiliation(s)
- A I M Miguel
- Ophthalmology Department, Central University Hospital of Coimbra, Coimbra, Portugal.
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A case of adult-onset Still's disease complicated by thrombotic thrombocytopenic purpura with retinal microangiopathy and rapidly fatal cerebral edema. Mod Rheumatol 2012; 23:379-85. [PMID: 22623015 DOI: 10.1007/s10165-012-0650-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 03/29/2012] [Indexed: 10/28/2022]
Abstract
We present a patient who had adult-onset Still's disease (AOSD) complicated by thrombotic thrombocytopenic purpura (TTP) that resulted in retinal microangiopathy and rapidly fatal cerebral edema. The patient was a 37-year-old male who developed fever, eruption, arthritis and hepatic dysfunction, that, based on close examination, was diagnosed as AOSD. Despite treatment with corticosteroids, the patient developed acute visual field defect, neurological deterioration including convulsions and impaired consciousness, as well as acute renal failure that ultimately resulted in death. Pathological examination of autopsy specimens revealed multiple fibrin thrombi disseminated in small vessels of the brain and kidney, which was consistent with TTP, along with marked cerebral edema. Although TTP has rarely been reported in association with AOSD, awareness of the possible coexistence of these two diseases is important for diagnosis and treatment.
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Bader-Meunier B, Monnet D, Barnerias C, Halphen I, Lambot-Juhan K, Chalumeau M, Costedoat-Chalumeau N, Ribeil JA, Bodemer C, Gherardi R. Thrombotic microangiopathy and Purtscher-like retinopathy as a rare presentation of juvenile dermatomyositis. Pediatrics 2012; 129:e821-4. [PMID: 22311994 DOI: 10.1542/peds.2011-0338] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Juvenile dermatomyositis is a rare systemic vasculopathy that may sometimes present with acute complications. We report here the case of a 7-year-old boy with severe dermatomyositis associated with thrombocytopenia and blurry vision. The presence of schistocytosis and the secondary occurrence of hemolytic anemia were consistent with a diagnosis of thrombotic thrombocytopenic purpura (TTP). Further investigations demonstrated the association of TTP with muscular microangiopathy and Purtscher-like retinopathy. Retinal and hematologic involvements dramatically improved after the initiation of plasma exchange in emergency. This report emphasizes that early recognition of TTP and prompt plasmapheresis are important in a child with severe juvenile dermatomyositis associated with thrombocytopenia.
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Affiliation(s)
- Brigitte Bader-Meunier
- Department of Pediatric Immunology and Rheumatology, Paris Descartes University, Necker Hospital, AP-HP, Paris, France.
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El Karoui K, Karras A, Lebrun G, Charles P, Arlet JB, Jacquot C, Orssaud C, Nochy D, Pouchot J. Thrombotic microangiopathy and purtscher-like retinopathy associated with adult-onset Still's disease: a role for glomerular vascular endothelial growth factor? ACTA ACUST UNITED AC 2010; 61:1609-13. [PMID: 19877102 DOI: 10.1002/art.24826] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Khalil El Karoui
- Faculté de Médecine Paris Descartes, Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
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Thrombotic microangiopathy in adult-onset Still's disease: case report and review of the literature. Wien Klin Wochenschr 2009; 121:583-8. [DOI: 10.1007/s00508-009-1217-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Accepted: 05/20/2009] [Indexed: 10/20/2022]
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Abstract
Adult onset Still's disease is a rare, febrile, multisystem rheumatic disease with unknown etiology, which runs an intermittent course and can either go into remission after months to years or progress to a chronic course with substantial joint destruction. The prevalence of this disease has been increasing in the last decade presumably caused by better diagnostic tools but also by a higher awareness among physicians taking care of patients with "fever of unknown origin". This review is intended to augment this trend, since research on the role of proinflammatory cytokines in this disease has led to an improved diagnostic and therapeutic repertoire over the last few years. Ferritin and interleukin-18 serum levels are valuable diagnostic parameters and blockade of interleukin-1, interleukin-6, and tumor-necrosis-factor alpha can effectively control the inflammatory activity of this disease in most cases and also in life-threatening conditions.
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Affiliation(s)
- B Manger
- Medizinische Klinik III, Klinikum der Friedrich-Alexander-Universität, Krankenhausstr. 12, 91054, Erlangen, Deutschland.
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Proença Pina J, Ssi-Yan-Kai K, de Monchy I, Charpentier B, Offret H, Labetoulle M. [Purtscher-like retinopathy: case report and review of the literature]. J Fr Ophtalmol 2008; 31:609-13. [PMID: 18772813 DOI: 10.1016/s0181-5512(08)75463-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purtscher's retinopathy is a rare condition, seen in patients with a history of trauma. Purtscher-like retinopathy includes the nontraumatic causes of this retinal disease, which is often misdiagnosed. The diagnosis is based on clinical settings and is supported by intravenous fluorescein angiography. We describe a case of acute, severe retinopathy in a patient experiencing a scleroderma renal crisis. We discuss the pathogeny, prognosis and treatment, which is still widely controversial.
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Affiliation(s)
- J Proença Pina
- Service d'Ophtalmologie, CHU Bicêtre, APHP, Université Paris-Sud, Le Kremlin Bicêtre, France.
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Gianella S, Schaer DJ, Schwarz U, Kurrer M, Heppner FL, Fehr J, Seebach JD. Retinal microangiopathy and rapidly fatal cerebral edema in a patient with adult-onset Still's disease and concurrent macrophage activation syndrome. Am J Hematol 2008; 83:424-7. [PMID: 18183612 DOI: 10.1002/ajh.21084] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a complex inflammatory disease with multiple diagnostic and therapeutic pitfalls. The congenital form, referred to as familial hemophagocytic lymphohistiocytosis (FHL), is often associated with cerebromeningeal involvement, whereas neurological complications are not characteristic of the adult form of secondary HLH (sHLH). Here we report the case of a 20-year-old woman with adult-onset Still's disease (AOSD), retinal microangiopathy and concurrent macrophage activation syndrome (MAS), in the context of sHLH. Following treatment with etanercept, ibuprofen, methylprednisolone, and phenylbutazone for 3 weeks, MAS deteriorated and fatal cerebral edema occurred within only 24 h. The clinical signs and neuropathological findings are discussed with special emphasis on possible relationships between the aggravation of MAS and therapeutic interventions for AOSD. In conclusion, even the slightest sign of mental decline in a patient with AOSD must be considered central nervous system MAS which can be rapidly fatal.
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Affiliation(s)
- Sara Gianella
- Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland.
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Sayarlioglu M, Sayarlioglu H, Ozkaya M, Balakan O, Ucar MA. Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome and adult onset Still's disease: case report and review of the literature. Mod Rheumatol 2008; 18:403-6. [PMID: 18427722 DOI: 10.1007/s10165-008-0061-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Accepted: 02/20/2008] [Indexed: 10/22/2022]
Abstract
Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP/HUS) is a multisystem disorder characterized by consumptive thrombocytopenia, microangiopathic hemolytic anemia, neurologic symptoms, renal function abnormalities, and fever. Coexistence of TTP/HUS and adult onset Still's disease (ASD) is extremely rare. We report the case of a 46-year-old woman who presented with fever, arthritis, myalgias, petechia on skin and confusion five years after the onset of ASD. Thrombocytopenia, renal failure, marked elevation lactate dehydrogenase, and red cell fragmentation on peripheral blood smear were observed. We made a diagnosis of TTP/HUS associated with ASD, according to physical examination and characteristic laboratory data. She recovered from the TTP/HUS following daily sessions of therapeutic plasma exchange with fresh frozen plasma replacement and glucocorticoid therapy. Awareness of the possible development of TTP/HUS in ASD is important for early diagnosis and treatment.
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Affiliation(s)
- Mehmet Sayarlioglu
- Department of Internal Medicine, Division of Rheumatology, Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey.
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