Rheumatoid hyperviscosity: analysis of a patient with intermediate complexes that block other autoantibodies and a review of the literature

The utility of therapeutic plasma exchange in Hyperviscosity syndrome associated with juvenile rheumatoid arthritis: A case report

Hyperviscosity syndrome (HVS) is a life-threatening syndrome caused by high concentrations of large plasma proteins like IgM, rheumatoid factor, and other immune complexes, leading to increased blood viscosity and symptoms such as visual abnormalities, neurological impairment, bleeding diathesis, and thrombosis. While Waldenström's macroglobulinemia accounts for 80% to 90% of cases, HVS may develop in other clinical settings characterized by elevations in plasma proteins. Limited evidence currently exists describing the safety and efficacy of therapeutic plasma exchange (TPE) for the management of HVS secondary to non-neoplastic conditions. We report a case of recurrent HVS associated with juvenile rheumatoid arthritis and Felty syndrome that demonstrated improvement in clinical symptoms following initiation of TPE. These findings suggest that TPE may be utilized as an adjunct treatment option in patients with HVS secondary to autoimmune disorders.

Therapeutic plasma exchange for hyperviscosity syndrome secondary to high rheumatoid factor

Hyperviscosity syndrome (HVS) is most commonly associated with Waldenstrom's macroglobulinemia, where it may be life-threatening. HVS may also occur in autoimmune diseases; data pertaining to efficacy of therapeutic plasma exchange (TPE) in HVS arising in non-malignant gammopathy are limited. We report a case of 71-year-old female with erosive rheumatoid arthritis with profoundly elevated rheumatoid factor (57,400 IU/ml; normal <35) who presented with findings consistent with HVS: profound weakness, headache, epistaxis and plasma viscosity (8.5 centipoise). She was successfully treated with pulsed high-dose steroids and TPE. Her symptoms of HVS have not recurred and the plasma viscosity has remained less than 3 centipoise. Given a slow onset of non-specific symptoms, HVS may be missed, incurring high risk of adverse effect. In symptomatic patients with high RF activity, a high index of suspicion for HVS is necessary to ensure timely identification and treatment with TPE, a safe and effective therapy.

Hyperviscosity in primary Sjögren's syndrome: clinical implications

AIM

Increased serum viscosity is recognized in primary Sjögren's syndrome (pSS); however, a classic hyperviscosity syndrome (HVS) is rare. We compared the clinical and serological profile among three groups of pSS patients: (i) with HVS; (ii) with high serum viscosity (≥ 1.9 cP [centipoises]) but without HVS; and (iii) with normal viscosity (< 1.9 cP).

METHODS

We identified four pSS patients with HVS and retrospectively assessed their clinical/serological features. We included as controls 62 pSS patients and registered their clinical features. We also measured the serum viscosity, C3, C4, immunoglobulins and evaluated the European League Against Rheumatism SS Disease Activity Index (ESSDAI) score at the last visit. We used χ² , Mann-Whitney U-tests and logistic regression analysis.

RESULTS

Patients were predominantly female (95%), mean age 54 ± 14.2 years, median disease duration 9 years. All the HVS cases were diagnosed concomitantly with the onset of SS and had higher titers of immunoglobulin G (IgG), IgM, IgA and a higher prevalence of vasculitis, neutropenia, lymphopenia and splenomegaly. At the multivariate analysis, the variables vasculitis odds ratio (OR) 14.8 (95% CI 1.3-99, P = 0.02) and splenomegaly OR 25.3 (95% CI 1.68-380, P = 0.01) remained associated with HSV. Viscosity levels correlated with rheumatoid factor titers. Thirty (48.3%) patients had high viscosity but without HSV; this group had higher median ESSDAI scores and more vasculitis than patients with normal viscosity.

CONCLUSION

High viscosity was present in almost half of the patients and was associated with vasculitis and higher activity scores. Conversely, HVS was infrequent and was associated with vasculitis and splenomegaly. It seems that both conditions have different physiopathological, clinical and treatment implications.

Autoimmunity and oxidatively modified autoantigens

Oxidative damage mediated by reactive oxygen species results in the generation of deleterious by-products. The oxidation process itself and the proteins modified by these molecules are important mediators of cell toxicity and disease pathogenesis. Aldehydic products, mainly the 4-hydroxy-2-alkenals, form adducts with proteins and make them highly immunogenic. Proteins modified in this manner have been shown to induce pathogenic antibodies in a variety of diseases including systemic lupus erythematosus (SLE), alcoholic liver disease, diabetes mellitus (DM) and rheumatoid arthritis (RA). 8-oxodeoxyguanine (oxidatively modified DNA) and oxidized low-density lipoproteins (LDL) occur in SLE, a disease in which premature atherosclerosis is a serious problem. In addition, immunization with 4-hydroxy-2-nonenal (HNE) modified 60 kD Ro autoantigen induces an accelerated epitope spreading in an animal model of SLE. Advanced glycation end product (AGE) pentosidine and AGE modified IgG have been shown to correlate with RA disease activity. Oxidatively modified glutamic acid decarboxylase is important in type 1 DM, while autoantibodies against oxidized LDL are prevalent in Behcet's disease. The fragmentation of scleroderma specific autoantigens occurs as a result of oxidative modification and is thought to be responsible for the production of autoantibodies through the release of cryptic epitopes. The administration of antioxidants is a viable untried alternative for preventing or ameliorating autoimmune disease, particularly on account of the overwhelming evidence for the involvement of oxidative damage in autoimmunity. However, this should be viewed in the light of disappointing results obtained with the use of antioxidants in cardiovascular disease.

[Blood viscosity profile in rapidly progressive sensorineural hearing loss with positive Western-blot]

OBJECTIVE

To value a possible association between disorders in blood viscosity of patients with rapidly progressive sensorineural hearing loss (RPSHL) of autoimmune origin.

PATIENTS AND METHODS

We studied the viscoelastic properties of blood in 43 subjects bearing of RPSHL and a positive Western-blot for anticochlear antibodies: whole blood viscosity (WBV) at different shear rates and erythrocyte filterability (EF). These results were related to hearing loss initially detected and recovery average one year later from steroid therapy.

RESULTS

Just WBV at 230 sec(-1) shear rate was significatively higher in cases than in controls (p < 0.01). Hearing recovery degree correlated in an statistically way to increased values of EF (p < 0.01). There was no relation between initial hearing loss level and any rheology parameter.

CONCLUSIONS

Autoimmune RPSHL does not show a pathophysiology mechanism associated to blood hyperviscosity. So, rheoactive therapies as plasmapheresis warrant no clinical improvement.

New therapies: plasmapheresis, intravenous immunoglobulin, and monoclonal antibodies

Rheumatologic emergencies may pose a serious threat to life, and the treatment of patients with these illnesses continues to be challenging. In the last decade extensive animal and human research has led to development of new therapies. Considerable progress has been made in the therapy for RA. Newly developed biologic therapies have shown promising results in clinical studies, and two agents have already been approved by the FDA. These drugs are currently available for therapy and are under close postmarketing scrutiny to assess long-term efficacy and safety. Similar therapies are under investigation for SLE. Plasmapheresis, once used for many diseases, is now restricted mostly to conditions for which its use has been shown to be beneficial in randomized, controlled studies. Immunoadsorption is used to target specific disease-producing pathogens for removal during extracorporeal therapy. Evidence is accumulating for the use of IVIGs in several immune-mediated conditions. The outlook for some emergencies continues be grim, however, and various therapies are used based on evidence from anecdotal case reports and case series. The new therapies are relatively safe, but careful monitoring is needed, because there is potential for serious adverse events.