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He X, Jiang L, Hu L, Du P, Zhu M, Wu H, Zhao M, Lu Q. Mivebresib alleviates systemic lupus erythematosus-associated diffuse alveolar hemorrhage via inhibiting infiltration of monocytes and M1 polarization of macrophages. Int Immunopharmacol 2023; 120:110305. [PMID: 37182455 DOI: 10.1016/j.intimp.2023.110305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/23/2023] [Accepted: 05/05/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is a serious complication that can arise from systemic lupus erythematosus (SLE) and other autoimmune diseases. While current treatments for DAH have limitations and adverse side effects, recent evidence suggests that inflammatory macrophages play a crucial role in the development of DAH. In this study, we investigated Mivebresib, a BET protein-bromodomain-containing protein 4 (BRD4) inhibitor, as a potential treatment for DAH. RESULTS Our findings show that Mivebresib effectively protected C57BL/6J mice against pristane-induced DAH by inhibiting the migration and polarization of monocytes and macrophages, as well as pathogenic B and T cells. Specifically, Mivebresib modified the distribution of leukocytes, impeded the polarization of inflammatory macrophages, and reduced the frequency of CD19 + CD5 + B cells in the lungs of pristane-treated mice. Furthermore, in vitro experiments demonstrated that Mivebresib inhibited LPS-induced M1 polarization of macrophages and the expression of pro-inflammatory cytokines, M1 marker genes, and chemokines-chemokine receptors while thwarting the secretion of IL-6 and TNF-α. Transcriptomic analysis suggested and experiments comfimed that Mivebresib inhibits M1 polarization via interrupting the p300/BRD4/HIF1A axis. CONCLUSIONS Our study demonstrates that Mivebresib has therapeutic potential for the life-threatening complication of DAH caused by SLE. By inhibiting macrophage polarization and the infiltration of inflammatory cells, Mivebresib may offer a promising treatment option for patients suffering from this disease.
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Affiliation(s)
- Xieling He
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Li Jiang
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Longyuan Hu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Pei Du
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ming Zhu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Haijing Wu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ming Zhao
- Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences, Nanjing, China; Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China; Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China; Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital, Central South University, Changsha, China.
| | - Qianjin Lu
- Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences, Nanjing, China; Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China; Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China; Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital, Central South University, Changsha, China.
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Diffuse Alveolar Hemorrhage: A Cohort of Patients With Systemic Lupus Erythematosus. J Clin Rheumatol 2021; 26:S153-S157. [PMID: 31895107 DOI: 10.1097/rhu.0000000000001228] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Diffuse alveolar hemorrhage (DAH) is an uncommon but potentially fatal complication in patients with systemic lupus erythematosus (SLE). Its prognosis and factors associated with mortality are not completely clear, although invasive mechanical ventilation (IMV), use of cyclophosphamide, a high Acute Physiology and Chronic Health Evaluation II score, and infections are associated with high mortality rates. We investigated clinical and immunologic characteristics and factors associated with mortality in a cohort of Latin American patients with SLE who developed DAH. METHODS A medical records review study was conducted of patients with SLE who were admitted to the intensive care unit (ICU) with DAH between 2011 and 2018. Clinical, laboratory, and treatment variables were compared between survivors and nonsurvivors. RESULTS A total of 17 patients with SLE presented with DAH during the study period, of whom 11 (64.70%) were women. The median age was 28 (19-38.5) years. The Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) on admission to the ICU was 15.94 ± 10.07. All patients received pulse methylprednisolone and therapeutic plasma exchange, and 13 (76. %) also received cyclophosphamide. During the hospital stay, 5 patients (29.41%) died. A high SLEDAI on admission, low albumin, and days of IMV and inotropic/vasoactive support were statistically significant in comparing nonsurvivors with survivors. Other scales of disease severity commonly used in the ICU, however, were not significantly associated with a fatal outcome. CONCLUSIONS Hypoalbuminemia, longer duration of IMV or inotropic/vasoactive treatment, and a high SLEDAI are potential prognostic factors for mortality in patients with SLE and DAH admitted to the ICU.
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Ramphul M, Gallagher K, Warrier K, Jagani S, Bhatt JM. Why is a paediatric respiratory specialist integral to the paediatric rheumatology clinic? Breathe (Sheff) 2020; 16:200212. [PMID: 33447294 PMCID: PMC7792836 DOI: 10.1183/20734735.0212-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/01/2020] [Indexed: 12/20/2022] Open
Abstract
Systemic connective tissue diseases (CTDs) are characterised by the presence of autoantibodies and multiorgan involvement. Although CTDs are rare in children, they are associated with pulmonary complications, which have a high morbidity and mortality rate. The exact pathophysiology remains unclear. The pleuropulmonary complications in CTD are diverse in their manifestations and are often complex to diagnose and manage. The most common CTDs are discussed. These include juvenile systemic lupus erythematosus, juvenile dermatomyositis, juvenile systemic sclerosis, Sjögren's syndrome and mixed connective tissue disease. We describe the clinical features of the pleuropulmonary complications, focusing on their screening, diagnosis and monitoring. Treatment strategies are also discussed, highlighting the factors and interventions that influence the outcome of lung disease in CTD and pulmonary complications of treatment. Early detection and prompt treatment in a multidisciplinary team setting, including respiratory and rheumatology paediatricians and radiologists, is paramount in achieving the best possible outcomes for these patients.
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Affiliation(s)
- Manisha Ramphul
- Dept of Paediatric Respiratory Medicine, Nottingham Children's Hospital, Nottingham University Hospitals, Nottingham, UK
| | - Kathy Gallagher
- Dept of Paediatric Respiratory Medicine, Nottingham Children's Hospital, Nottingham University Hospitals, Nottingham, UK
| | - Kishore Warrier
- Dept of Paediatric Respiratory Medicine, Nottingham Children's Hospital, Nottingham University Hospitals, Nottingham, UK
| | - Sumit Jagani
- Dept of Radiology, Nottingham University Hospitals, Nottingham, UK
| | - Jayesh Mahendra Bhatt
- Dept of Paediatric Respiratory Medicine, Nottingham Children's Hospital, Nottingham University Hospitals, Nottingham, UK
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Pulmonary manifestations in systemic lupus erythematosus: pleural involvement, acute pneumonitis, chronic interstitial lung disease and diffuse alveolar hemorrhage. ACTA ACUST UNITED AC 2019; 14:294-300. [PMID: 29773465 DOI: 10.1016/j.reuma.2018.03.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/28/2018] [Accepted: 03/22/2018] [Indexed: 12/29/2022]
Abstract
Systemic lupus erythematosus is the diffuse autoimmune connective tissue disease that most frequently involves pulmonary involvement, affecting 20% of 90% of the patients. The percentage varies depending on the defining criteria (symptoms, pulmonary tests or histopathological studies). At least once during the disease course, 50% of those affected have pleural and/or pulmonary manifestations, which are associated with higher morbidity and mortality. Pulmonary involvement has no correlation with lupus activity biomarkers, and it is necessary to rule out infectious processes in the initial approach. Bacterial infection is most frequently the cause of lung involvement in lupus and is one of the most important causes of death. Pulmonary involvement is considered to be primary when it is associated with disease activity, and secondary when other causes participate. Drugs have been reported to be associated with pulmonary damage, including interstitial disease. The incidence of malignant lung diseases is increased in systemic lupus erythematosus. Treatment depends on the type and severity of pulmonary involvement.
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Wang CR, Liu MF, Weng CT, Lin WC, Li WT, Tsai HW. Systemic lupus erythematosus-associated diffuse alveolar haemorrhage: a single-centre experience in Han Chinese patients. Scand J Rheumatol 2018; 47:392-399. [PMID: 29916287 DOI: 10.1080/03009742.2017.1420817] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Despite aggressive therapeutic regimens, diffuse alveolar haemorrhage (DAH) is still associated with a high mortality rate in systemic lupus erythematosus (SLE). This study was carried out in patients with SLE-associated DAH with a focus on their therapeutic modality. METHOD A retrospective review was performed in 839 Han Chinese lupus patients hospitalized for their DAH manifestation from May 2006 to December 2016. RESULTS There were 24 episodes in 17 cases (2.0% incidence), 15 females and two males aged 19-67 years (mean ± sd 38.2 ± 15.1 years). High disease activity [Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) 12-31, 19.8 ± 5.6] was found at the onset of DAH. All patients were treated with high-dose corticosteroid, followed by pulse methylprednisolone (70.6%), plasmapheresis (41.2%), pulse cyclophosphamide (35.3%), and rituximab (23.5%). Six patients (35.3%), including three with extracorporeal membrane oxygenation, died owing to acute respiratory failure. All patients receiving rituximab treatment survived with a follow-up period of 12-58 months (40.8 ± 21.1 months), and no further relapse was noted in three cases with a history of recurrent DAH episodes. In addition, there was a significant decrease in their lupus activity (SLEDAI-2K 21.5 ± 6.0 to 6.3 ± 1.7, p = 0.0286). CONCLUSION In this single-centre series with SLE-associated DAH in Han Chinese patients, a beneficial effect of rituximab therapy was observed.
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Affiliation(s)
- C-R Wang
- a Section of Rheumatology , National Cheng Kung University Hospital , Tainan , Taiwan
| | - M-F Liu
- a Section of Rheumatology , National Cheng Kung University Hospital , Tainan , Taiwan
| | - C-T Weng
- a Section of Rheumatology , National Cheng Kung University Hospital , Tainan , Taiwan
| | - W-C Lin
- b Section of Critical Care Medicine, Department of Internal Medicine , National Cheng Kung University Hospital , Tainan , Taiwan
| | - W-T Li
- b Section of Critical Care Medicine, Department of Internal Medicine , National Cheng Kung University Hospital , Tainan , Taiwan
| | - H-W Tsai
- c Department of Pathology , National Cheng Kung University Hospital , Tainan , Taiwan
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Cucuzza ME, Marino SD, Schiavone L, Smilari P, Filosco F, Barone P. Diffuse alveolar haemorrage as initial presentation of systemic lupus erythematosus: a case report. Lupus 2018; 27:507-510. [DOI: 10.1177/0961203317713144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Diffuse alveolar haemorrhage (DAH) is a rare life-threatening complication of systemic lupus erythematosus (SLE), associated with high mortality rates. It usually occurs in patients with an established diagnosis of SLE. It has been reported as the initial presentation of SLE in 11−20% of cases. It occurs most frequently in females. We describe the case of a child, aged 14 years, with fever, asthenia, haemoptysis, dyspnea, anaemia, increased inflammatory markers, positivity to ANA, nDNA, direct Coombs tests, anticardiolipin antibodies and complement factors consumption. Computed tomography (CTscan) of the chest showed bilateral pulmonary alveolar infiltrates. He also developed renal involvement with nephritis later in the course of the disease. He was started on the treatment approved by the Euro Lupus Protocol for critical patients. After starting Mycophenolate Mofetil the clinical and radiological features were improved as was the survival outcome.
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Affiliation(s)
- M E Cucuzza
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - S D Marino
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - L Schiavone
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - P Smilari
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - F Filosco
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - P Barone
- Department of Clinical and Experimental Medicine, University of Catania, Italy
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Continous Rituximab treatment for recurrent diffuse alveolar hemorrhage in a patient with systemic lupus erythematosus and antiphosholipid syndrome. Respir Med Case Rep 2017; 22:263-265. [PMID: 29021954 PMCID: PMC5633164 DOI: 10.1016/j.rmcr.2017.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 09/26/2017] [Accepted: 09/28/2017] [Indexed: 12/20/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare but potentially fatal complication in systemic lupus erythematosus (SLE). DAH is typically characterized by hemoptysis, dyspnea, new infiltrates on chest x-rays or CT-scans and a drop in hemoglobin. DAH is seen in less than 2% of patients with SLE and carries a high acute mortality risk of up to 70–90%. The current treatment of DAH is high-dose intravenous corticosteroids, cyclophosphamide and extensive supportive care. Plasmapheresis is also often considered in the treatment. A few case reports have described patients with SLE and DAH in whom a single series of Rituximab (RTX), a specific anti-CD20-antigen B-cell antibody, successfully has been used to treat DAH. We here present the first case of a patient with combined SLE, antiphospholipid syndrome (APS) and recurrent DAH who was successfully controlled by continued treatment with RTX.
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Efficacy of Rituximab in a Systemic Lupus Erythematosus Patient Presenting with Diffuse Alveolar Hemorrhage. Case Rep Rheumatol 2017; 2017:6031053. [PMID: 29259835 PMCID: PMC5705898 DOI: 10.1155/2017/6031053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/17/2017] [Accepted: 10/22/2017] [Indexed: 11/17/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of systemic lupus erythematosus (SLE). Although infrequent, its mortality is very high. While there are no established therapeutic guidelines, DAH has been traditionally managed with high-dose intravenous (IV) corticosteroids, cyclophosphamide, and plasma exchange. The efficacy of alternative therapies such as rituximab has been described only in a few cases. Herein, we report a 25-year-old Hispanic man who presented with acute-onset SLE manifested by polyarthralgia, nephritis, seizures, pancytopenia, severe hypocomplementemia, and elevated anti-dsDNA antibodies. His disease course was complicated by DAH. His condition was refractory to high-dose intravenous (IV) methylprednisolone pulses, IV cyclophosphamide, and plasmapheresis. Given the lack of clinical response, he was started on IV rituximab 375 mg/m2 weekly for a total of four courses. He rapidly improved after the first two doses. Over the next seven months, he did not present recurrent pulmonary symptoms. Follow-up chest computed tomography did not show residual abnormalities. This case, together with other reports, suggests that rituximab is an effective therapeutic option for DAH in SLE.
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Finucci Curi P, Pierrestegui M, Ortiz A, Ceccato F, Paira S. Hemorragia pulmonar en pacientes con lupus eritematoso sistémico. Características clínicas y pronóstico. Med Clin (Barc) 2015; 145:375-9. [DOI: 10.1016/j.medcli.2014.07.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/04/2014] [Accepted: 07/07/2014] [Indexed: 10/24/2022]
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10
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Kazzaz NM, Coit P, Lewis EE, McCune WJ, Sawalha AH, Knight JS. Systemic lupus erythematosus complicated by diffuse alveolar haemorrhage: risk factors, therapy and survival. Lupus Sci Med 2015; 2:e000117. [PMID: 26430514 PMCID: PMC4586940 DOI: 10.1136/lupus-2015-000117] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 08/14/2015] [Accepted: 08/28/2015] [Indexed: 01/09/2023]
Abstract
Objectives While diffuse alveolar haemorrhage (DAH) is recognised as a life-threatening complication of systemic lupus erythematosus (SLE), little is known about its risk factors and response to treatment. We describe 22 cases of DAH in a US lupus cohort of approximately 1000 patients, and compare them to 66 controls from the same outpatient cohort. Methods We captured variables pertaining to diagnoses of SLE and secondary antiphospholipid syndrome (APS), and analysed them by univariate testing. Those variables with p values <0.05 were then further considered in a multivariate model. Kaplan-Meier curves were constructed for each group, and survival was analysed by Log-rank test. Results Of the 22 patients with DAH, 59% were diagnosed with DAH within 5 years of lupus diagnosis. By univariate testing, several manifestations of SLE and APS were more common in patients with DAH, including history of thrombocytopenia, cardiac valve disease, low C3, leucopenia, neuropsychiatric features, haemolysis, arterial thrombosis, lupus anticoagulant, secondary APS and low C4. On multivariate analysis, history of thrombocytopenia and low C3 were maintained as independent risk factors. Importantly, only two patients had platelet counts <50 000/µL at the time of the DAH episode, arguing that DAH was not simply a haemorrhagic complication of thrombocytopenia. All patients were treated with increased immunosuppression, including various combinations of corticosteroids, plasmapheresis, cyclophosphamide, rituximab and mycophenolate mofetil. Notably, all patients in the cohort survived their initial episode of DAH. While the patients with DAH did well in the short-term, their long-term survival was significantly worse than controls. Several of the deaths were attributable to thrombotic complications after recovering from DAH. Conclusions To the best of our knowledge, this is the largest case–control study of lupus DAH to date. History of thrombocytopenia was strongly predictive of DAH (OR ∼40). A number of APS manifestations correlated with DAH by univariate analysis, and deserve further consideration in larger studies.
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Affiliation(s)
- Nayef M Kazzaz
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Patrick Coit
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Emily E Lewis
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - W Joseph McCune
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Amr H Sawalha
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Jason S Knight
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
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Schwarz MI. A deadly complication of systemic lupus erythematosus. J Rheumatol 2015; 41:1571-2. [PMID: 25086137 DOI: 10.3899/jrheum.140613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Marvin I Schwarz
- University of Colorado Denver, Pulmonary Sciences and Critical Care Medicine, Aurora, Colorado, USA.
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12
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Parrot A, Fartoukh M, Cadranel J. Hémorragie intra-alvéolaire. Rev Mal Respir 2015; 32:394-412. [DOI: 10.1016/j.rmr.2014.11.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 06/06/2014] [Indexed: 10/24/2022]
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Na JO, Chang SH, Seo KH, Choi JS, Lee HS, Lyu JW, Nah SS. Successful Early Rituximab Treatment in a Case of Systemic Lupus Erythematosus with Potentially Fatal Diffuse Alveolar Hemorrhage. Respiration 2015; 89:62-5. [DOI: 10.1159/000369038] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 09/26/2014] [Indexed: 11/19/2022] Open
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Tse JR, Schwab KE, McMahon M, Simon W. Rituximab: an emerging treatment for recurrent diffuse alveolar hemorrhage in systemic lupus erythematosus. Lupus 2014; 24:756-9. [DOI: 10.1177/0961203314564235] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 11/20/2014] [Indexed: 11/15/2022]
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare manifestation of systemic lupus erythematosus (SLE) and is associated with high mortality rates. Treatment typically consists of aggressive immunosuppression with pulse-dose steroids, cyclophosphamide, and plasma exchange therapy. Mortality rates remain high despite use of multiple medical therapies. We present a case of recurrent DAH in a 52-year-old female with SLE after a deceased donor renal transplant who was successfully treated with rituximab. Our report highlights the pathophysiologic importance of B-cell-mediated immunosuppression in SLE-associated DAH and suggests that rituximab may represent a viable alternative to cyclophosphamide in the treatment of this disease. We also review eight other reported cases of rituximab use in SLE-associated DAH.
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Affiliation(s)
- J R Tse
- Department of Medicine, 1Division of General Internal Medicine
| | - K E Schwab
- Department of Medicine, 1Division of General Internal Medicine
| | - M McMahon
- Division of Rheumatology, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - W Simon
- Department of Medicine, 1Division of General Internal Medicine
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Esper RC, Estrada IEDLM, de la Torre León T, Gutiérrez AOR, López JAN. Treatment of diffuse alveolar hemorrhage secondary to lupus erythematosus with recombinant activated factor VII administered with a jet nebulizer. J Intensive Care 2014; 2:47. [PMID: 25705408 PMCID: PMC4336265 DOI: 10.1186/s40560-014-0047-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 07/21/2014] [Indexed: 11/10/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a serious pulmonary complication in patients with autoimmune diseases who are undergoing chemotherapy or have had hematopoietic stem cell transplantation. The use of recombinant factor VIIa (rFVIIa) to treat the acute phase of DAH by endobronchial bronchoscopy has been shown to have a significant clinical impact on the survival and evolution of these patients. We report a clinical case of a patient with DAH secondary to systemic lupus erythematosus (SLE) who was treated with rFVIIa administered using a jet nebulizer, obtaining an adequate hemostatic effect with immediate control of DAH and a significant improvement in gas exchange.
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Affiliation(s)
- Raúl Carrillo Esper
- Unidad de Terapia Intensiva, Fundación Clínica Médica Sur, Puente de Piedra 150, Col. Toriello Guerra. Delegación Tlalpan, Mexico, DF 14050 Mexico
| | | | - Teresa de la Torre León
- Unidad de Terapia Intensiva, Fundación Clínica Médica Sur, Puente de Piedra 150, Col. Toriello Guerra. Delegación Tlalpan, Mexico, DF 14050 Mexico
| | - Agustín Omar Rosales Gutiérrez
- Unidad de Terapia Intensiva, Fundación Clínica Médica Sur, Puente de Piedra 150, Col. Toriello Guerra. Delegación Tlalpan, Mexico, DF 14050 Mexico
| | - Jorge Arturo Nava López
- Unidad de Terapia Intensiva, Fundación Clínica Médica Sur, Puente de Piedra 150, Col. Toriello Guerra. Delegación Tlalpan, Mexico, DF 14050 Mexico
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Chance, genetics, and the heterogeneity of disease and pathogenesis in systemic lupus erythematosus. Semin Immunopathol 2014; 36:495-517. [PMID: 25102991 DOI: 10.1007/s00281-014-0440-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 06/30/2014] [Indexed: 12/30/2022]
Abstract
Systemic lupus erythematosus (SLE) is a remarkably complex and heterogeneous systemic autoimmune disease. Disease complexity within individuals and heterogeneity among individuals, even genetically identical individuals, is driven by stochastic execution of a complex inherited program. Genome-wide association studies (GWAS) have progressively improved understanding of which genes are most critical to the potential for SLE and provided illuminating insight about the immune mechanisms that are engaged in SLE. What initiates expression of the genetic program to cause SLE within an individual and how that program is initiated remains poorly understood. If we extrapolate from all of the different experimental mouse models for SLE, we can begin to appreciate why SLE is so heterogeneous and consequently why prediction of disease outcome is so difficult. In this review, we critically evaluate extrinsic versus intrinsic cellular functions in the clearance and elimination of cellular debris and how dysfunction in that system may promote autoimmunity to nuclear antigens. We also examine several mouse models genetically prone to SLE either because of natural inheritance or inheritance of induced mutations to illustrate how different immune mechanisms may initiate autoimmunity and affect disease pathogenesis. Finally, we describe the heterogeneity of disease manifestations in SLE and discuss the mechanisms of disease pathogenesis with emphasis on glomerulonephritis. Particular attention is given to discussion of how anti-DNA autoantibody initiates experimental lupus nephritis (LN) in mice.
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Hemorragia alveolar difusa en pacientes con lupus eritematoso sistémico. Manifestaciones clínicas, tratamiento y pronóstico. ACTA ACUST UNITED AC 2014; 10:248-53. [DOI: 10.1016/j.reuma.2014.02.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/03/2014] [Accepted: 02/14/2014] [Indexed: 01/08/2023]
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Affiliation(s)
- Ruchi Dua
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Jagdish Rawat
- Pulmonary Medicine, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India E-mail:
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Zhang Y, Xia Y, Ni S, Gu Z, Liu H. Transplantation of umbilical cord mesenchymal stem cells alleviates pneumonitis of MRL/lpr mice. J Thorac Dis 2014; 6:109-17. [PMID: 24605224 DOI: 10.3978/j.issn.2072-1439.2013.12.48] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 12/28/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate whether the umbilical cord mesenchymal stem cells (UC-MSCs) transplantation in the MRL/lpr mice has effect or not on their pneumonitis and the possible mechanisms underlying this treatment. METHODS Twenty four 18-week-old MRL/lpr female mice were divided into three groups as following: the group 2 (UC-MSCT group) have been transplanted with 1×10(6) UC-MSCs through caudal vein, the group 3 (multi-UC-MSCT Group) have been transplanted with 1×10(6) UC-MSCs three times and the group 1 (control group) have been treated with 0.5 mL phosphate buffer saline (PBS) as control. The histopathology of the lung was observed. The pulmonary expression of high mobility group box protein-1 (HMGB-1) was measured by western blot and detected by quantitation real time polymerase chain reaction (PCR). Immunohistochemistry method was used to detect HMGB-1 expressions in pulmo. RESULTS In comparision to control ground mice, UC-MSCs significantly reduced interstitial pneumonitis in the MRL/lpr mice. The lung peribronchiolar lesion index of UC-MSCT group (1.40±0.24) and multi-UC-MSCT group (1.02±0.29) were significantly decreased as compared to control group (1.95±0.35) (P<0.01). The perivascular lesion index of UC-MSCT group (1.20±0.18) and multi-UC-MSCT group (1.08±0.16) were also significantly reduced as compared to control group (1.56±0.32) (P=0.018, 0.002) and the lung alveolar areas lesion index of control group (1.72±0.34) was significantly increased as compared to UC-MSCT group (1.30±0.21) and multi-UC-MSCT group (1.05±0.15) (P=0.011, 0.000). The lung HMGB-1 protein in UC-MSCT group (0.32±0.04) and in multi-UC-MSCT group (0.28±0.06) were both significantly decreased as compared to that in control group (0.80±0.21) (P<0.05). The level of HMGB-1 mRNA in UC-MSCT group (4.68±0.37) and in multi-UC-MSCT group (4.35±0.10) lung were both significantly decreased as compared to those in control group (16.29±3.84) (P<0.05). In immunohistochemical staining lung sections, high expression of HMGB-1 was found mainly located in the cytoplasm and extracellular matrix of MRL/lpr mice pulmonary epithelial cells, the expression of HMGB-1 in UC-MSCT group and multi-UC-MSCT group was significantly decreased as compared to that in the control group. CONCLUSIONS These findings indicate that UC-MSCs have a therapeutic effect on systemic lupus erythematosus (SLE) pneumonitis, possibly by inhibiting HMGB-1 expression, which suggests a potential application of UC-MSCs in the treatment of human lupus.
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Affiliation(s)
- Yanju Zhang
- 1 Department of Respiratory Medicine, 2 Department of Rheumatology Medicine, Affiliated Hospital of Nantong University, Nantong 226001, China
| | - Yunfei Xia
- 1 Department of Respiratory Medicine, 2 Department of Rheumatology Medicine, Affiliated Hospital of Nantong University, Nantong 226001, China
| | - Songshi Ni
- 1 Department of Respiratory Medicine, 2 Department of Rheumatology Medicine, Affiliated Hospital of Nantong University, Nantong 226001, China
| | - Zhifeng Gu
- 1 Department of Respiratory Medicine, 2 Department of Rheumatology Medicine, Affiliated Hospital of Nantong University, Nantong 226001, China
| | - Hua Liu
- 1 Department of Respiratory Medicine, 2 Department of Rheumatology Medicine, Affiliated Hospital of Nantong University, Nantong 226001, China
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Gómez Carrera L, Bonilla Hernan G. Pulmonary manifestations of collagen diseases. Arch Bronconeumol 2013; 49:249-60. [PMID: 23683373 DOI: 10.1016/j.arbres.2012.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 11/18/2012] [Accepted: 11/20/2012] [Indexed: 10/27/2022]
Abstract
Collagen diseases are a large group of systemic inflammatory diseases of autoimmune etiology. The etiopathogenesis of collagen diseases is multifactorial. There is genetic susceptibility, as many connective tissue disorders show family history, and environmental factors may trigger the disease. Collagen diseases can affect almost all the organs of the body. The respiratory system is one of the most frequently affected, although the prevalence of pulmonary disease is not precisely known for the different collagen disorders. Any structure of the respiratory tract can be affected, but perhaps the most frequent is pulmonary parenchymal disease in the form of pneumonitis, which can be produced in any of the idiopathic interstitial pneumonitis patterns. The pleura, pulmonary vessels, airways and respiratory muscles may also be affected. The frequency of lung disease associated with collagen diseases is on the rise. This due in part to the better diagnostic methods that are available to us today (such as high-resolution computed tomography) and also to the appearance of new forms of pneumonitis associated with the new treatments that are currently used. The objective of this article is to offer a global vision of how collagen diseases can affect the lungs according to the latest scientific evidence.
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Affiliation(s)
- Luis Gómez Carrera
- Servicio de Neumología, IdiPAZ, Hospital Universitario La Paz, Madrid, Spain.
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Rituximab: rescue therapy in life-threatening complications or refractory autoimmune diseases: a single center experience. Rheumatol Int 2012; 33:1495-504. [DOI: 10.1007/s00296-012-2587-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 11/30/2012] [Indexed: 10/27/2022]
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Shi D, Wang D, Li X, Zhang H, Che N, Lu Z, Sun L. Allogeneic transplantation of umbilical cord-derived mesenchymal stem cells for diffuse alveolar hemorrhage in systemic lupus erythematosus. Clin Rheumatol 2012; 31:841-6. [PMID: 22302582 DOI: 10.1007/s10067-012-1943-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 12/21/2011] [Accepted: 01/16/2012] [Indexed: 01/15/2023]
Abstract
Umbilical cord-derived mesenchymal stem cell transplantation (UC-MSCT) has been proved to be effective in the treatment of systemic lupus erythematosus (SLE), based on animal experiments and clinical trials. Diffuse alveolar hemorrhage (DAH) is a rare complication of SLE with a high mortality usually over 50%. This study aimed to assess the efficacy of UC-MSCT in the treatment of SLE-associated DAH. Four SLE patients complicated with DAH, who underwent UC-MSCT, were included. Clinical changes before and after transplantation were assessed by measurements of hemoglobin, platelet level, oxygen saturation, and serological factors. High-resolution CT (HRCT) scans of the chest were performed to evaluate pulmonary manifestation. All the four patients showed dramatic improvements of their clinical manifestations. Hemoglobin was elevated after UC-MSCT and was sustained at a normal level 6 months after UC-MSCT in the four patients. Platelet level was upregulated in two patients who had thrombocytopenia at baseline. Oxygen saturation appeared to be normal at 1 month after UC-MSCT, and this result was confirmed by the HRCT scan of the chest. Serum albumin elevated to 3.5 g/dl 6 months after transplantation. Our findings suggest that UC-MSCT results in amelioration of oxygen saturation as well as hematological and serologic changes, which revealed that UC-MSCT could be applied as a salvage strategy for DAH patients.
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Affiliation(s)
- Dongyan Shi
- Department of Immunology and Rheumatology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, People's Republic of China
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Diffuse alveolar hemorrhage: a rare life-threatening condition in systemic lupus erythematosus. Case Rep Pulmonol 2012; 2012:836017. [PMID: 22934226 PMCID: PMC3420594 DOI: 10.1155/2012/836017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 03/06/2012] [Indexed: 11/17/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare life-threatening complication in systemic lupus erythematosus (SLE) associated with high mortality rates. DAH is more common in women, and mean age of onset is around 30 years. It mostly occurs in patients with established diagnosis of SLE but can be the initial presentation of lupus in approximately 20%. DAH should be suspected in lupus patient presenting with new pulmonary infiltrates, decline in hemoglobin, hemoptysis, dyspnea, hypoxemia, and increase in carbon monoxide diffusion capacity. Radiographic evidence of bilateral pulmonary alveolar infiltrates that are usually perihilar or basilar with sparing of apices is seen. DAH can often mimic clinically and radiologically severe pneumonia or ARDS. Treatment includes high-dose corticosteroids, cyclophosphamide, and plasmapheresis. We report a case of diffuse alveolar hemorrhage complicating SLE flare-up in a male patient.
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Rashidi AA, Alajmi M, Hegazi MO. Mycophenolate mofetil as a maintenance therapy for lupus-related diffuse alveolar hemorrhage: a case report. Lupus 2011; 20:1551-1553. [DOI: 10.1177/0961203311411353] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of systemic lupus erythematosus (SLE). Cases complicated with DAH often have active SLE with multi-organ involvement, especially lupus nephritis. We describe a rare case of DAH as the first presenting manifestation of SLE in the absence of lupus nephritis. Remission was induced by IV methylprednisolone, IV cyclophosphamide, and plasmapheresis. Further cycles of cyclophosphamide were prevented by recurrent infections. Maintenance of remission was successfully achieved with oral mycophenolate mofetil 1 g twice daily, with a good control of SLE and without further DAH episodes.
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Affiliation(s)
| | - M Alajmi
- Medical Department, Al Adan Hospital, Kuwait
| | - MO Hegazi
- Medical Department, Al Adan Hospital, Kuwait
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Aringer M, Burkhardt H, Burmester GR, Fischer-Betz R, Fleck M, Graninger W, Hiepe F, Jacobi AM, Kötter I, Lakomek HJ, Lorenz HM, Manger B, Schett G, Schmidt RE, Schneider M, Schulze-Koops H, Smolen JS, Specker C, Stoll T, Strangfeld A, Tony HP, Villiger PM, Voll R, Witte T, Dörner T. Current state of evidence on 'off-label' therapeutic options for systemic lupus erythematosus, including biological immunosuppressive agents, in Germany, Austria and Switzerland--a consensus report. Lupus 2011; 21:386-401. [PMID: 22072024 DOI: 10.1177/0961203311426569] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Systemic lupus erythematosus (SLE) can be a severe and potentially life-threatening disease that often represents a therapeutic challenge because of its heterogeneous organ manifestations. Only glucocorticoids, chloroquine and hydroxychloroquine, azathioprine, cyclophosphamide and very recently belimumab have been approved for SLE therapy in Germany, Austria and Switzerland. Dependence on glucocorticoids and resistance to the approved therapeutic agents, as well as substantial toxicity, are frequent. Therefore, treatment considerations will include 'off-label' use of medication approved for other indications. In this consensus approach, an effort has been undertaken to delineate the limits of the current evidence on therapeutic options for SLE organ disease, and to agree on common practice. This has been based on the best available evidence obtained by a rigorous literature review and the authors' own experience with available drugs derived under very similar health care conditions. Preparation of this consensus document included an initial meeting to agree upon the core agenda, a systematic literature review with subsequent formulation of a consensus and determination of the evidence level followed by collecting the level of agreement from the panel members. In addition to overarching principles, the panel have focused on the treatment of major SLE organ manifestations (lupus nephritis, arthritis, lung disease, neuropsychiatric and haematological manifestations, antiphospholipid syndrome and serositis). This consensus report is intended to support clinicians involved in the care of patients with difficult courses of SLE not responding to standard therapies by providing up-to-date information on the best available evidence.
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Affiliation(s)
- M Aringer
- Rheumatology, Medicine III, University Medical Center TU Dresden, Germany.
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Abstract
Diffuse alveolar hemorrhage is an uncommon, yet often fatal, complication of systemic lupus erythematosus (SLE). Advances in the treatment of alveolar hemorrhage have been hampered because of the heterogeneity of clinical findings and the lack of suitable animal models. A single intraperitoneal injection of pristane induces a lupus-like syndrome characterized by lupus-related autoantibodies and glomerulonephritis in non-autoimmune-prone strains of mice. In addition, C57BL/6 (B6) mice frequently develop alveolar hemorrhage within a few weeks of pristane injection. Immunopathogenesis of pristane-induced alveolar hemorrhage was investigated in the present study. Early (2-4 weeks after injection) mortality due to hemorrhage was unique to C57BL/6 and C57BL/10 strains of mice. Recruitment of the macrophages and neutrophils preceded the hemorrhage by several days, and hemorrhage started 3-7 days after pristane injection in some mice, peaked at 2 weeks (84% in B6) and then resolved by 4 weeks in a majority of mice. Alveolar hemorrhage was independent of MyD88 (myeloid differentiation factor 88), or TLR7 pathways, in contrast to autoantibody production and glomerulonephritis, and was also independent of FcγR or Fas. Rag1(-/-) mice had a reduced prevalence of alveolar hemorrhage compared with B6 (P=0.01) congenics. However, T-cell receptor-deficient mice developed alveolar hemorrhage at a rate comparable to wild-type controls, whereas B6 Igμ(-/-) mice surprisingly had a strikingly reduced prevalence (7% vs 84% in B6, P<0.0001). Reconstitution of B6 Igμ(-/-) mice with wild-type B cells increased the prevalence to 50% (P=0.028). Pristane-induced alveolar hemorrhage is a useful model to study the pathogenesis and develop new therapy for this underappreciated and often life-threatening complication of SLE.
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Martínez-Martínez MU, Abud-Mendoza C. Predictors of mortality in diffuse alveolar haemorrhage associated with systemic lupus erythematosus. Lupus 2011; 20:568-574. [DOI: 10.1177/0961203310392430] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
The objective of this study was the evaluation of clinical, demographic and treatment-associated mortality factors in patients with diffuse alveolar haemorrhage (DAH) associated with systemic lupus erythematosus (SLE). Clinical, laboratory test, SLEDAI-2K, predictors of mortality (APACHE II) and different treatments including cyclophosphamide, methylprednisolone and rituximab were evaluated in SLE patients who were diagnosed with DAH, to determine potential association with mortality. Twenty-nine episodes of DAH in 22 SLE patients were included (one patient with four episodes, four patients with two episodes (seven recurrences)), 15 died. Mean age was 25.1 years and 1.5 years of SLE evolution with haemoglobin drop 3.4 g/dl. In 4 of 22 patients, the DAH diagnosis was confirmed by autopsy. Six episodes were in patients under 18 years of age (2 patients with recurrence). DAH was the initial manifestation of SLE in 10 patients. Of the 22 patients, 17 were women and 22/29 had DAH episodes. Dyspnoea and nephritis occurred in all patients, less common were arthritis (75.9%) and fever (65.5%); haemoptysis was present only in 44.8%. Through evaluation of all included factors, only thrombocytopenia, renal failure, requirement for mechanical ventilation and high APACHE II were associated with higher mortality. Cyclophosphamide use was associated with less mortality (not statistically significant).
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Affiliation(s)
- MU Martínez-Martínez
- Regional Unit of Rheumatology and Osteoporosis, Central Hospital ‘Dr. Ignacio Morones Prieto’ and Faculty of Medicine, Universidad Autónoma de San Luis Potosí, San Luis Potosí, México
| | - C Abud-Mendoza
- Regional Unit of Rheumatology and Osteoporosis, Central Hospital ‘Dr. Ignacio Morones Prieto’ and Faculty of Medicine, Universidad Autónoma de San Luis Potosí, San Luis Potosí, México
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Pottier V, Pierrot M, Subra JF, Mercat A, Kouatchet A, Parrot A, Augusto JF. Successful rituximab therapy in a lupus patient with diffuse alveolar haemorrhage. Lupus 2011; 20:656-9. [PMID: 21335399 DOI: 10.1177/0961203310386276] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diffuse alveolar haemorrhage (DAH) is a rare but life-threatening complication of systemic lupus erythematosus (SLE). Specific therapy is based on a heavy immunosuppressive treatment that usually associates corticosteroid and cyclophosphamide boluses and plasma exchange. Despite this treatment, an early mortality rate of 20-50% is reported in the literature. Immunosuppression-related complications are responsible for further mortality and morbidity. Rituximab, a specific anti-CD20 antigen B-cell antibody, has been used with success for the treatment of several refractory autoimmune disorders, but rarely for SLE-induced DAH. We report here the first case of SLE-induced DAH treated successfully with rituximab without cyclophosphamide administration in a patient intolerant to cyclophosphamide. We review the two other cases of SLE-induced DAH managed with rituximab as a part of the immunosuppressive regimen.
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Affiliation(s)
- V Pottier
- Département de Réanimation médicale et Médecine hyperbare, CHU Angers, Angers F-49933, France
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Narshi CB, Haider S, Ford CM, Isenberg DA, Giles IP. Rituximab as early therapy for pulmonary haemorrhage in systemic lupus erythematosus. Rheumatology (Oxford) 2009; 49:392-4. [PMID: 19926673 DOI: 10.1093/rheumatology/kep356] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Diffuse alveolar hemorrhage as an unusual presentation of systemic lupus erythematosus. Rheumatol Int 2009; 31:1085-7. [PMID: 19908046 DOI: 10.1007/s00296-009-1227-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Accepted: 10/07/2009] [Indexed: 11/27/2022]
Abstract
Diffuse alveolar hemorrhage (DAH) is rarely seen in patients with systemic lupus erythematosus (SLE), often associated with a poor outcome. It almost affects young women and it is an unusual initial manifestation of SLE. We report a case of SLE presenting with DAH. The patient was a male. He had no history of photosensitivity, malar rash, discoid rash, arthritis, and oral ulcer. Antinuclear antibody, and anti-double stranded DNA (dsDNA) were positive with very high titers, and serum complement levels (C3, C4) were low. He also had renal dysfunction and pericardial effusion. He was diagnosed as DAH due to SLE. He had to undergo hemodialysis for several weeks. DAH and renal dysfunction were improved with intensive treatment including corticosteroid, cyclophosphamide, and mycophenolate mophetil.
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Abstract
Diffuse alveolar haemorrhage (DAH) is a rare but life-threatening complication of systemic lupus erythematosus (SLE). We present the case of a 24-year-old Cambodian woman with SLE followed in the Brigham and Women’s Hospital Lupus Center in Boston, Massachusetts. She presented with dyspnoea and chest pain and was found to have DAH that required a prolonged hospitalization that was complicated by recurrent DAH episodes and multiple infections. We discuss the diagnostic approach and management of patients with SLE-associated DAH as well as treatment options for refractory disease. Emerging therapies include plasmapheresis, the anti-CD20 monoclonal antibody rituximab and recombinant activated Factor VII therapy. In addition, we review the literature to date and compile what is known about the epidemiology, presenting features, diagnostic findings, management and outcomes in this condition. We found that DAH has been reported in 1.9% of patients with SLE. These patients were mostly female (88%) and young (mean age 30.2 years). Common presenting features included dyspnoea (94%), anaemia (97%) and new radiographic chest infiltrate (99%). Bronchoscopy, when performed, identified DAH in 90% of cases. Corticosteroids were the mainstay of care, and usage of cyclophosphamide varied by report. Despite recent advances in therapy, mortality has not improved substantially (48% overall survival versus 53% survival in reports published since 1993).
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Affiliation(s)
- DJ Todd
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital, Arthritis Center, Boston, Massachusetts, USA
| | - KH Costenbader
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital, Arthritis Center, Boston, Massachusetts, USA
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Porres-Aguilar M, Mendez-Ramirez, J, Eraso, LH, Porres-Munoz, M, Pema, K. Diffuse Alveolar Hemorrhage as an Initial Presentation of Systemic Lupus Erythematosus. J Natl Med Assoc 2008; 100:1485-7. [DOI: 10.1016/s0027-9684(15)31553-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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