Usefulness of glycosylated ferritin in atypical presentations of adult onset Still's disease

[Still's disease in sub-Saharan Africa through ten observations from the internal medicine department of Libreville University Hospital (Gabon)]

Introduction

Introduction. Still's Disease (SD) is a rare systemic inflammatory disorder that is most common in children. In the adult form, it can be primary or the resurgence of an infantile form. We report 10 observations of Still's disease in the Gabonese population, with the aim of confirming its existence in this country an studying its specific features.

Material and methods

This was a retrospective, descriptive and analytical study carried out in the Internal Medicine Department of the CHU of Libreville from 1.12.2003 to 31.12.2021, using the records of patients hospitalized in this department and/or followed up on an outpatient basis. The selected patients fulfilled the Yamaguchi and Fautrel criteria. Epidemiologic, socioeconomic, clinical, biological, morphologic, immunologic, therapeutic, evolutionary and seasonal data were detailed.

Results

Ten patients (4 men and 6 women), mostly students with a mean age of 22 years, were included. The time to diagnosis of SD was 31.3 months, with fever in 100% of cases, joint and skin involvement in 80%, and ENT involvement in 70%. An inflammatory syndrome, predominantly neutrophilic hyperleukocytosis, hepatic signs, and hyperferritinemia coexisted with an immunologic work-up that was always negative. Corticosteroid therapy (n=10) combined with per os methotrexate from the beginning (n=1) or in cases of corticoresistance (n=4) was the rule. One patient died and one was lost to follow-up.

Discussion and conclusion

The clinical and biological presentation of SD is comparable to that of the Caucasian population. However, our study confirms in the low incidence of liver, lymph node and heart damage, which needs to be confirmed by other studies in a larger cohort. The high cost of this disease, which is a diagnosis of exclusion, may partly explain the difficulties in diagnosing SD.

Guillain-Barre Syndrome as an Atypical Early Presentation of Adult-Onset Still's Disease: A Case Report

Adult-onset Still's disease (AOSD) is a rare auto-inflammatory disorder with unknown pathophysiology. Although having a heterogeneous clinical spectrum, the major features of AOSD include fever, rash, and arthritis or arthralgia. Neurological involvement is rare in AOSD with aseptic meningitis being the most common presentation. Guillain-Barre syndrome (GBS) has never been reported as an early presentation of AOSD. Herein, we describe the case of a patient presenting with GBS and fever of unknown origin who was soon diagnosed with AOSD and improved with corticosteroid therapy.

Fulminant elderly adult-onset Still disease effectively treated with tocilizumab and methotrexate: A case report

RATIONALE

Adult-onset Still disease (AOSD) is a rare inflammatory disease of unknown etiology. AOSD is common in young or middle-aged adults; however, in recent years, there have been increasing reports of elderly AOSD. Differentiating AOSD from diseases such as infections and malignancies is difficult. Moreover, rare fulminant AOSD cases with resistance to corticosteroids and immunosuppressive drugs have been reported.

PATIENT CONCERNS

An 80-year-old woman presented with flaccid fever, generalized arthralgia, and erythema of the anterior chest for 2 weeks. On day 5 of hospitalization, the patient developed pleural effusion with hypoxemia and her vital signs indicated rapid progression to shock. During the clinical course, the levels of inflammatory markers, including maximum level of ferritin and white blood cells (WBCs) were elevated (252,796 ng/mL and 86,500/μV, respectively) with disseminated intravascular coagulation syndrome (DIC) and macrophage activation syndrome (MAS).

DIAGNOSIS

The patient was diagnosed with elderly AOSD as per the Yamaguchi criteria for AOSD. The state of disease was extremely severe with rapid progression and was, thus, categorized as a fulminant form of elderly AOSD.

INTERVENTIONS

The patient was treated with prednisolone (PSL) pulse therapy (1000 mg/d) twice and plasma exchange in the intensive care unit for the primary disease and shock. Although she recovered from shock, she developed DIC and MAS. Methotrexate (MTX; 10 mg/d) improved the DIC and MAS. However, severe pleuritis recurred and the patient developed pericarditis; her primary disease was poorly controlled. Finally, tocilizumab (TCZ) was introduced using interleukin-18 (IL-18) as a surrogate marker. The IL-18 level was measured repeatedly following admission, with the peak level (170,000 pg/mL) recorded on the 75th day of hospitalization, immediately prior to introducing TCZ.

OUTCOMES

The combined use of MTX, TCZ, and PSL was effective in suppressing elderly AOSD, which was unsuccessfully controlled with MTX and PSL. Frequent monitoring of IL-18 levels proved useful for differentiating elderly AOSD from other diseases.

LESSONS

A fulminant form of elderly AOSD was treated with a combination of MTX, TCZ, and PSL. Repeated monitoring of IL-18 levels can be useful for decision-making in treating elderly AOSD.

Catastrophic adult-onset Still's disease as a distinct life-threatening clinical subset: case-control study with dimension reduction analysis

Objectives

Adult-onset Still’s disease (AOSD) is a rare systemic inflammatory disorder. Diagnosing AOSD can be challenging, as disease presentation and clinical course are highly heterogeneous. For unclear reasons, a few patients develop life-threatening complications. Our objective was to determine whether these cases resulted from therapeutic delay or could represent a peculiar AOSD subset.

Methods

We conducted a multicentre retrospective study of 20 AOSD patients with organ failure requiring intensive care unit admission and 41 control AOSD patients without organ failure. Clinico-biological data at hospital admission were explored using supervised analyses and unsupervised dimension reduction analysis (factor analysis of mixed data, FAMD).

Results

Disease duration before admission was shorter in patients with life-threatening AOSD (median, 10 vs 20 days, p = 0.007). Disease duration before AOSD therapy initiation also tended to be shorter (median, 24 vs 32 days, p = 0.068). Despite this shorter disease duration, FAMD, hierarchical clustering and univariate analyses showed that these patients exhibited distinctive characteristics at first presentation, including younger age; higher frequency of splenomegaly, liver, cardiac and/or lung involvement; less frequent arthralgia; and higher ferritin level. In multivariate analysis, 3 parameters predicted life-threatening complications: lack of arthralgia, younger age and shorter time between fever onset and hospitalisation.

Conclusion

This study suggests that life-threatening complications of AOSD occur very early, in a peculiar subset, which we propose to name catastrophic adult-onset Still’s disease (CAOSD). Its exact burden may be underestimated and remains to be clarified through large multicentre cohorts. Further studies are needed to identify red flags and define the optimal therapeutic strategy.

Adult onset Still's disease in the elderly: a case-based literature review

Background

Adult onset Still’s disease (AOSD) is a rare inflammatory disorder that classically presents with high spiking fevers, evanescent rash, and arthritis. The diagnosis is one of exclusion and can be further complicated by atypical presentations, particularly in elderly patients in whom AOSD is very rare.

Case presentation

A case of AOSD in a 73-year-old woman with a non-classic presentation, leading to delayed diagnosis and management, is presented along with a review of the English literature for AOSD cases in elderly people over 70 years of age. Thirty nine case reports and series were identified and the current case was added, totaling 42 individual cases. Significant findings included a four-times higher prevalence in females, a higher prevalence of macrophage activation syndrome despite lower mortality, the presence of pruritic rash in almost one fifth of the cases, and high prevalence of delayed diagnosis.

Conclusions

AOSD in the elderly may vary from the classic criteria described in the medical literature and may lead to delayed diagnosis and management. Further evaluation and better characterization of AOSD in the elderly remains an area of interest.

Elderly-onset Still's Disease Complicated by Macrophage Activation Syndrome: A Case Report and Review of the Literature

Adult-onset Still's disease (AOSD) usually affects young adults. Some cases of elderly-onset Still's disease (EOSD) have been reported, but its clinical features are unclear. We herein report a 74-year-old woman who developed AOSD with macrophage activation syndrome (MAS). We also reviewed 24 previous EOSD cases in patients over 70 years old and compared the findings with overall AOSD. While the clinical features were similar between the two, including the presence of MAS, disseminated intravascular coagulation was more frequent in EOSD than in AOSD. Furthermore, despite a similar frequency of glucocorticoid use, immunosuppressants and biologics were less frequently administered in EOSD than in AOSD. This report highlights the fact that typical AOSD can develop in elderly patients with some characteristic features.

Clinical features and prognosis of adult-onset Still's disease: 75 cases from China

This study evaluated the clinical characteristics, treatment outcomes, and complications of patients with adult onset Still's disease (AOSD) in our local Chinese population. Patients with AOSD attending our hospital from 2008 to 2011 were identified and followed up. Their clinical and laboratory features at presentation, as well as their disease progression, treatments, and outcomes were recorded and compared with other reported series. A total of 75 patients with AOSD were identified. Forty-four were female. Thirty-nine had disease onset between 16 and 35 years of age. The most common presenting features were fever (96%), arthritis (57.33%), rash (78.67%), and sore throat (49.3%). The acute phase response was marked in most patients, with elevated erythrocyte sedimentation rates (77.05%) and C-reactive protein levels (84.06%). Hyperferritinemia was present in 74.14% of cases, and serum ferritin (SF) levels declined after treatment in most cases. Liver abnormalities were usually transient, but were more severe in 5 patients. Most patients (92%) required corticosteroid therapy; of these, 33.3% also received disease-modifying antirheumatic drugs or immunosuppressive drugs. Sixty-four and 45.33% patients with AOSD achieved partial and complete remission, respectively, after 2 weeks of treatment, and 92% and 74.67%, respectively, after 1 month. The cumulative relapse rate was 45.3%. Patients with AOSD had complex symptoms with no specific laboratory findings. Reduced SF levels after treatment and liver abnormalities may be used to follow treatment outcome.

An Unusual Case of Adult-Onset Still's Disease with Hemophagocytic Syndrome, Necrotic Leukoencephalopathy and Disseminated Intravascular Coagulation

Case. A 34-year-old African-American female with a history of adult-onset Still's disease presented to an outside hospital with oligoarthritis. She experienced a generalized tonic-clonic seizure en route via ambulance, was intubated upon arrival, and transferred to the intensive care unit for treatment of suspected pneumonia and sepsis. She subsequently developed generalized cutaneous desquamation that progressed despite the cessation of antibiotics and other potential offending drugs which required transfer to our hospital's burn unit. She was suspected to have reactive hemophagocytic syndrome based on her clinical presentation of fever, rash, polyarthritis, elevated liver enzymes, coagulopathy, splenomegaly, normocytic anemia, thrombocytopenia, hypertriglyceridemia, hyperferritinemia, and hemophagocytosis visualized in bone marrow biopsy specimen. Magnetic resonance imaging demonstrated necrotic demyelination of the deep white matter and corona radiata. The patient developed multiorgan dysfunction and DIC without any other attributable etiology. Despite aggressive broad spectrum therapy and high dose of steroids she progressively deteriorated and eventually expired. Conclusion. Previous publications have highlighted the prevalence of necrotic leukoencephalopathy in children with familial hemophagocytic syndrome. Our patient demonstrated some uncommon features complicating her HLH including DIC and necrotic leukoencephalopathy, which are very rare entities in AOSD.

Screening tests for inflammatory activity: applications in rheumatology

Inflammation is a hallmark of rheumatic diseases. The response to tissue injury comprises a series of changes which result in the shedding of pathogens, limitation of tissue damage and restoration of affected structures. These changes depend on increased or decreased serum concentrations of certain proteins known as inflammatory biomarkers. Laboratory analysis of these markers, together with clinical data and other complementary tests enable the assessment of disease activity and treatment response and can indicate the presence of infection. The screening tests currently available for identifying inflammatory activity include the determination of C-reactive protein level and erythrocyte sedimentation rate as well as protein electrophoresis. Here, we review the characteristics of a number of inflammatory biomarkers and their use in the assessment of inflammatory activity in rheumatic diseases.

Adult onset Still's disease: a study of 14 cases

We studied the clinical profile, laboratory parameters, disease course, and outcomes of patients with adult onset Still's disease (AOSD). A retrospective analysis of adult patients with Still's disease diagnosed from 2000 to 2004 was carried out. Their clinical features and laboratory findings at presentation, disease course, and outcomes were analyzed. Data of 14 patients with Still's disease were analyzed. The age at disease onset ranged from 16 to 59 years with a mean of 29.85, the male to female ratio being 9:5. The mean duration of illness from onset of symptoms to presentation was 14.5 months (range). The most common clinical manifestations were fever (n = 14), articular symptoms (n = 14), rash (n = 8), weight loss (n = 12), and sore throat (n = 5). Elevated ESR was present in all patients with a mean of 98.3 mm at 1 h. Hepatic enzymes were elevated in seven patients at disease onset. The mean duration of follow up was 19.14 months (range). Three patients progressed to chronic arthropathy. Cyclosporine led to dramatic recovery in five patients. Macrophage activation syndrome (MAS) was present in two patients, one after sulfasalazine therapy. One patient with MAS died. Still's disease, although uncommon, has characteristic constellation of clinical and laboratory features and should be considered in the differential diagnosis of fever of unknown origin. Nonsteroidal anti-inflammatory drugs, steroids, and methotrexate may not be always effective, and cyclosporine is an effective drug in resistant cases. Sulfasalazine should be avoided in cases of AOSD.

Increased ferritin response in adult Still's disease: specificity and relationship to outcome

BACKGROUND

The disproportionate ferritin response encountered in some patients with adult Still's disease (ASD) may reflect a fundamental aspect in the pathophysiology of ASD.

METHODS

An observational case-control study of 22 ASD patients followed for 63 months. Baseline laboratory data were compared with age- and gender-matched controls with new-onset rheumatoid arthritis (RA). Serum levels of ferritin and C-reactive protein (CRP) and the ferritin/CRP ratio were related to clinical outcome in ASD through nonparametric statistical analyses.

RESULTS

Compared to RA patients, haemoglobin levels were lower (11.8 vs. 13.5 g/dL; p = 0.009) and leucocyte counts (17.1 vs. 8.6 10(9)/mL; p<0.001), erythrocyte sedimentation rate (ESR) (84 vs. 38 mm; p = 0.001), CRP (154 vs. 27 mg/L; p<0.001), aspartate aminotransferase (ASAT) (52 vs. 23 U/l; p = 0.004), serum ferritin (8750 vs. 62 microg/L; p<0.001) and ferritin/CRP ratios (9.7 vs. 1.7; p<0.001) were higher in ASD patients at baseline. Six patients (27%) achieved sustained remission (monocyclic disease), while 16 patients (73%) developed chronic disease (progressive in 27%, relapsing/remitting in 46%). The levels of ESR and CRP or other baseline variables were not associated with outcome. However, baseline serum ferritin was significantly higher in ASD patients with chronic disease (p = 0.04), while a cut-off of five times the normal upper level (NUL) was 100% sensitive and 60% specific for predicting chronic disease.

CONCLUSION

An exaggerated ferritin response with levels>5 times the NUL and high ferritin/CRP ratios is useful for distinguishing between ASD and RA patients. Ferritin levels>5 times the NUL are also associated with a chronic disease course.

Chronic Anemia and Thrombocytosis as the Initial Presentation of Still’s Disease in an Elderly Patient

Still's disease is very rare in elderly patients. We report a case of Still's disease in an elderly patient that had an atypical initial presentation. A 76-year-old woman developed unexplained chronic anemia and thrombocytosis. Three years later she had acute onset of high fever, arthritis, maculopapular rash, pleuritic chest pain, abdominal pain, lymphadenopathy and elevated erythrocyte sedimentation rate. Rheumatoid factor and antinuclear antibodies were negative. She responded favorably to prednisone and methotrexate treatment. Anemia and thrombocytosis as well as Still's disease manifestations resolved.

Reactive haemophagocytic syndrome in adult-onset Still's disease: a report of six patients and a review of the literature

OBJECTIVE

To examine the prevalence and characteristics of patients with reactive haemophagocytic syndrome (RHS) complicating adult-onset Still's disease (AOSD).

METHODS

Of 50 patients with AOSD fulfilling Yamaguchi and Fautrel criteria followed in our department, clinical and laboratory data, course and treatment of six patients with histologically proven RHS and without any obvious cause other than AOSD were retrospectively recorded.

RESULTS

RHS led to AOSD in two cases, whereas it appeared after a mean duration of 3.5 years from onset of AOSD in the other cases. The main symptoms were fever (n = 6), polyarthralgias or myalgias (n = 4), lymphadenopathy or splenomegaly (n = 3), pharyngitis (n = 3), rash (n = 3), pleuritis (n = 3), hepatomegaly (n = 1), normal or low leucocyte count (n = 4), anaemia (n = 6), lymphocytopenia (n = 6), thrombocytopenia (n = 4), hyperbasophilic lymphocytes (n = 2), abnormal liver function tests (n = 6) and increased serum triglyceride level (n = 6). Serum ferritin concentration was constantly increased (>10,000 microg/l in five cases, with <5-35% in glycosylated form). Two patients presented with coagulopathy. Treatment comprised corticosteroids (n = 4) and intravenous immunoglobulins (n = 3), whereas prednisone was unchanged in one case. One death due to pneumonia occurred 15 days after RHS. With a follow-up ranging from 2 to 7.5 years, the other patients were in remission with prednisone plus etanercept (n = 1), prednisone plus methotrexate (n = 1), low-dose prednisone (n = 2) or without treatment (n = 1).

CONCLUSION

RHS is not uncommon in AOSD. It should be evoked in a patient with AOSD in the absence of hyperleucocytosis, thrombocytopenia, lymphopenia and coagulopathy, or in the presence of high serum ferritin and triglyceride levels.

[Current concepts on the physiopathology of adult-onset Still's disease]

PURPOSE

Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder of unknown origin. It is characterized by hectic fever, evanescent rash, polyarthralgias or polyarthritis, sore throat, hepatosplenomegaly, lymphadenopathy, polynuclear leukocytosis, liver cytolysis, and high serum level of ferritin with low glycosylated fraction.

CURRENT KNOWLEDGE AND KEY POINTS

An increased serum level of ferritin, IL-8, IL-6, IL-18 and TNF-alpha indicates that macrophages are highly activated in AOSD. Interleukin 18 (IL-18) seems to be a key cytokine in the pathogenesis of AOSD. Serum IL-18 levels are increased in AOSD patients compared to other systemic inflammatory diseases such as rheumatoid arthritis and they are well correlated with serum ferritin levels and disease activity. IL-18 could cause acute liver injury and arthritis. Macrophages could be activated by infectious agents such as viruses and by an inadequate control of T cell response secondary to depressed Natural Killer lymphocyte function, similarly to that observed in systemic juvenile idiopathic arthritis. Sustained macrophage activation can lead to the hemophagocytic syndrome, a severe complication of both AOSD and systemic juvenile idiopathic arthritis.

FUTURE PROSPECTS

Cytotoxic cell functions should be probably studied in AOSD as they were in the hemophagocytic syndrome and systemic juvenile idiopathic arthritis because AOSD, characterised by a marked macrophage activation may be related to an immunological deficiency.