Thrombotic microangiopathy in adult-onset Still's disease: case report and review of the literature

Thrombotic thrombocytopenic purpura in a patient with adult-onset Still's disease: report of a rare entity

Adult-onset Still's disease (AOSD) is a rare, systemic inflammatory disorder characterised by daily fever, arthritis, a salmon-pink rash and leucocytosis. Thrombotic thrombocytopenic purpura (TTP) is included in the class of thrombotic microangiopathies and manifests clinically as microangiopathic haemolytic anaemia (MAHA), thrombocytopenia and ischaemic tissue injury secondary to microthrombi. TTP is caused by either an autoimmune, congenital or idiopathic deficiency of ADAMTS13 and carries a high mortality rate. TTP can be seen in patients diagnosed with other rheumatologic conditions, with systemic lupus erythematosus being the most common, but is rarely seen in AOSD. Permanent complication rates from TTP in the setting of AOSD have been reported to be >50%. This case study aims to report one of the rare instances of TTP presenting in a patient with known AOSD to broaden the knowledge base regarding these rare coexisting pathologies.

Adult-onset Still's disease with concurrent thrombotic microangiopathy: Observations from pooled analysis for an uncommon finding

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.

Emergency Mechanical Thrombectomy for Acute Middle Cerebral Artery Occlusion Accompanied by Adult-Onset Still's Disease

Adult-onset Still's disease (AOSD) is a rare systemic inflammatory condition of an unknown etiology. Stroke is a rare complication associated with AOSD; most of these are cerebral infarctions due to the occlusion of small blood vessels. Here, we report the first case of mechanical thrombectomy in a patient with cerebral infarction due to a large vessel occlusion associated with AOSD. A 60-year-old man with no underlying disease was diagnosed with AOSD. Sixteen days after admission, he suddenly lost consciousness and was found to have right hemiplegia and aphasia. Head CT showed early signs of ischemic infarction in the left insular cortex, and head CT angiography demonstrated occlusion in a part of the left middle cerebral artery (MCA). Therefore, we decided that mechanical thrombectomy was an indication of revascularization. We performed mechanical thrombectomy using a Trevo NXT 4 × 28 mm (Stryker, Kalamazoo, USA) and obtained reperfusion of the MCA. The results of the cerebral angiography were indicative of an embolic cerebral infarction, and we investigated the source of the embolism including an insertable cardiac monitor (ICM) (Reveal LINQ, Medtronic, Minneapolis, USA). However, no disease other than AOSD that could be a source of embolism was observed. Therefore, AOSD was assumed to be associated with embolisms. AOSD may cause embolic cerebral infarction and may be indicated for mechanical thrombectomy.

Recurrent deep venous thromboses in a patient with adult-onset Still's disease

Adult-onset Still's disease (AOSD) is a rare inflammatory disorder affecting just over one in a million people. Due to its rarity, understanding of its pathophysiology and the spectrum of its clinical associations are limited. Improved case identification and creation of patient registries have begun to reveal sporadic reports of deep venous thromboses associated with AOSD. Herein, we report the first case of recurrent deep venous thrombosis in a patient with AOSD despite treatment with therapeutic dose anticoagulant medication. This case points for a judicious approach to the selection of an anticoagulation strategy for deep venous thromboses in the setting of active AOSD. This case is of contemporary interest in its clinical similarity with COVID-19 symptoms and pathophysiology for which a careful diagnostic approach with a broad differential should be considered given the limitations of SARS-CoV-2 testing and the risk associated with treatment in the event of misdiagnosis.

Adult-onset Still's disease with concurrent thrombotic thrombocytopenic purpura: case report and literature review

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.

Pulmonary arterial hypertension in adult onset Still's disease: a case report of a severe complication

Background

Adult onset of Still’s disease (AOSD) is a rare systemic inflammatory disease. Cardiorespiratory complications are mainly represented by pleural and pericardial disorders and are less frequent than cutaneous and articular complaints. Pulmonary arterial hypertension (PAH) occurring in AOSD is rarely described in literature.

Case presentation

We present the case of a young patient who developed severe PAH 2 years after diagnosis of AOSD. This is a rare and severe complication which is probably underestimated.

Conclusions

PAH in AOSD can be lethal, and unfortunately its occurrence is unpredictable. Echocardiographic screening of AOSD patients should be evaluated in further trials. Currently, the most suitable treatment is still unknown.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0237-x) contains supplementary material, which is available to authorized users.

Thrombotic microangiopathy in a patient with adult-onset Still's disease

BACKGROUND

Since there are many disorders that can present with thrombotic microangiopathy (TMA), establishing a correct diagnosis is important to offer the most appropriate therapy.

CASE REPORT

A 26-year-old woman was transferred to our hospital with fragmentation hemolytic anemia, thrombocytopenia, and acute kidney failure. History revealed that she was recently diagnosed with adult-onset Still's disease (AOSD) and received intraocular injections of bevacizumab to treat acute retinal artery occlusion. At our hospital, she underwent extensive investigations and was treated with high-dose steroids, hemodialysis, and therapeutic plasma exchange. For recurrent disease, she received a single dose of eculizumab.

RESULTS

The patient's ADAMTS13 activity was normal and she had evidence of complement activation. Genetic testing identified a benign polymorphism in the C3 gene. Pathophysiology of TMA in AOSD is briefly discussed and an overview of the literature is presented.

CONCLUSION

Work-up of a new fragmentation hemolytic anemia and thrombocytopenia should include careful review of past history, including medications, as well as relevant laboratory investigations with aim to establish a correct diagnosis. Occasionally, the correct diagnosis is not the obvious one and there could be multiple contributors to the pathogenesis. Establishing diagnosis is important for counseling patient on disease prognosis and to guide treatment.

Adult-onset Still's disease

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.

A case of adult-onset Still's disease complicated by thrombotic thrombocytopenic purpura with retinal microangiopathy and rapidly fatal cerebral edema

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.

Thrombotic microangiopathy presenting with a considerable accumulation of ascites: a case report

A 46-year-old man presented with fever, thrombocytopenia, and a considerable accumulation of ascites. Although prednisolone and intravenous cyclophosphamide pulse (IVCY) were effective, he experienced recurrence. Renal insufficiency and hemolytic anemia developed subsequently. Schistocytes, negative Coombs' test, and elevated lactate dehydrogenase levels indicated thrombotic microangiopathy (TMA). He recovered well after receiving plasma infusion, IVCY, and prednisolone. Renal biopsy revealed subendothelial widening, thereby confirming TMA. This is a very rare case of TMA that presented with a considerable volume of ascites.