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Chang ES, Yu HH, Wu CE, Chan TM. Acute respiratory distress syndrome associated with macrophage activation syndrome in systemic lupus erythematosus: A case report and literature review. Medicine (Baltimore) 2022; 101:e28612. [PMID: 35119005 PMCID: PMC8812624 DOI: 10.1097/md.0000000000028612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/30/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Previous treatment for macrophage activation syndrome (MAS) includes high-dose intravenous methylprednisolone along with intravenous immunoglobulin G. If MAS worsened, second-line therapy consisted of anakinra; if the disease remained refractory, third-line therapy with etoposide was considered. In addition, cyclosporine A plays a role in early MAS and in preventing recurrence. Some studies have reported the use of cytokine-targeting agents other than anakinra, such as canakinumab, tocilizumab, abatacept, and tofacitinib. PATIENT CONCERNS The patient with systemic lupus erythematosus (SLE) had an uncommon combination of intermittent fever, hyperferritinemia, hypertriglyceridemia, jaundice, and significantly abnormal liver function test results. The patient reported a history of daily fever of 38 to 39°C, painful oral ulcer, anorexia, abdominal bloating, diarrhea, and malar rash progression for 2 weeks, and jaundice, tea-colored urine, and clay-colored stool for 1 week preceding hospital admission. DIAGNOSIS SLE flareups in the patient were initially suspected. However, the final diagnosis was acute respiratory distress syndrome (ARDS) associated with MAS. INTERVENTIONS The treatment included disease-modifying antirheumatic drugs (DMARDs), such as azathioprine, and titrated steroid doses of methylprednisolone (40 mg q8 h) and dexamethasone (15 mg q8 h), after the patient had ARDS and was intubated.Dose-adjusted monotherapy with dexamethasone was found to be effective; this may be attributed to some DMARDs being unsuitable for cytokine storms, that is, some DMARDs may cause complications in cytokine storms. OUTCOMES After dexamethasone 15 mg q8 h treatment, the patient's fever subsided within 2 days, and liver function became normal within 3 weeks. The patient regularly attended scheduled outpatient follow-up visits after discharge. After 2 years, the patient reported no symptoms or signs of SLE with 2 mg/d oral dexamethasone. LESSONS Early diagnosis of MAS and dexamethasone treatment for MAS with ARDS appear to be crucial for these patients.
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Affiliation(s)
- En-Shuo Chang
- Division of Nephrology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Han-Hua Yu
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Linkou branch, Taoyuan, Taiwan
| | - Chiao-En Wu
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou branch, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tien-Ming Chan
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Linkou branch, Taoyuan, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
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2
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Khan A, Anwer Khan S, Shamim R, Batool S, Aslam M. Experience with macrophage activation syndrome associated with systemic lupus erythematosus: A single-center study from Pakistan. Indian J Rheumatol 2022. [DOI: 10.4103/injr.injr_230_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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3
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Huang LW, Wei JCC, Chen DY, Chen YJ, Tang KT, Ko TM, Chen HH. Bidirectional association between systemic lupus erythematosus and macrophage activation syndrome: a nationwide population-based study. Rheumatology (Oxford) 2021; 61:1123-1132. [PMID: 34146089 DOI: 10.1093/rheumatology/keab502] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/09/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To determine the bidirectional relationship between macrophage activation syndrome (MAS) and systemic lupus erythematosus (SLE). METHODS Using the 1997-2013 Taiwan's National Health Insurance Research Database, we identified patients with newly diagnosed SLE from 2001 to 2013 from the whole beneficiaries and selected individuals without SLE from a one-million representative population. Propensity score (PS) matching was performed to balance incident SLE patients and individuals without SLE according to age, sex, comorbidities and medical utilization. The association between a history of MAS and SLE was studied using conditional logistic regression analysis shown as adjusted odds ratio (aOR). The risk of MAS associated with SLE was analyzed using Cox proportional regression analysis shown as hazard ratio (aHR), and we conducted a sensitivity analysis using various definitions of MAS. RESULTS We finally included 10,481 SLE patients and 20,962 PS-matched (1:2) non-SLE individuals. The correlation between a history of MAS and SLE did not reach statistical significance after adjustment for potential confounders (aOR, 1.18; 95% confidence interval, 0.80-1.75) in the age/sex-matched populations. In the 1:2 PS-matched populations, the risk of MAS markedly increased in patients with SLE (aHR, 7.18; 95% confidence interval, 4.97-10.36). Other risk factors for MAS included female, age ≥ 65 years, low income, a history of inflammatory bowel disease, and MAS history. CONCLUSION This nationwide, population-based study revealed that a history of MAS was not significantly associated with SLE risk. However, the risk of MAS was markedly associated with SLE and history of MAS.
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Affiliation(s)
- Lu-Wei Huang
- Department of Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - James Cheng-Chung Wei
- Department of Allergy, Immunology & Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan.,Institute of Medicine, College of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| | - Der-Yuan Chen
- Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan.,Translational Medicine Laboratory, Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan
| | - Yen-Ju Chen
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kuo-Tung Tang
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tai-Ming Ko
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University (NYCU), Tainan, Taiwan.,Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Hsin-Hua Chen
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Biomedical Science and Rong-Hsing Research Center for Translational Medicine, Chung-Hsing University, Taichung, Taiwan
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4
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Gerstein M, Borgia RE, Dominguez D, Feldman BM, Liao F, Levy DM, Ng L, Abdelhaleem M, Silverman ED, Hiraki LT. Predicting Macrophage Activation Syndrome in Childhood-onset Systemic Lupus Erythematosus Patients at Diagnosis. J Rheumatol 2020; 48:1450-1457. [PMID: 33262295 DOI: 10.3899/jrheum.200292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Macrophage activation syndrome (MAS), a life-threatening inflammatory complication, is increasingly recognized in childhood-onset systemic lupus erythematosus (cSLE). It can be a challenge to differentiate active cSLE from MAS. We generated decision rules for discriminating MAS from active cSLE in newly diagnosed patients. METHODS We conducted a retrospective cohort study of consecutive, newly diagnosed, active cSLE patients with fever, requiring hospital admission to The Hospital for Sick Children from January 2003 to December 2007 (cohort 1) and January 2008 to December 2013 (cohort 2). All patients met ≥ 4 American College of Rheumatology or Systemic Lupus International Collaborating Clinics criteria, and were steroid-naïve and infection-free. MAS was diagnosed based on expert opinion. Recursive partitioning was applied to each cohort to derive a decision rule based on clinical and laboratory features, distinguishing MAS from non-MAS cSLE. Each decision rule was applied to the alternate, independent cohort. Sensitivity and specificity of these decision rules were compared to existing criteria. RESULTS Cohort 1 (n = 34) and cohort 2 (n = 41) each had 10 patients with MAS. Recursive partitioning in cohort 1 identified ferritin ≥ 699 μg/L as the sole best discriminator between MAS and non-MAS patients (R2 = 0.48), and in cohort 2, ferritin ≥ 1107 μg/L was the best discriminator for MAS, followed by lymphocytes < 0.72 × 103/mm3 (R2 = 0.52). Cross-validation of our decision rules maintained 90-100% sensitivity and 65-85% specificity. CONCLUSION Our decision rule demonstrated improved performance compared to preliminary guidelines for MAS in cSLE from the Lupus Working Group of the Paediatric Rheumatology European Society and familial hemophagocytic lymphohistiocytosis diagnostic criteria. Validation in independent cohorts is required.
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Affiliation(s)
- Maya Gerstein
- M. Gerstein, MD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada, and Pediatric Rheumatology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - R Ezequiel Borgia
- R.E. Borgia, MD, Division of Rheumatology, The Hospital for Sick Children, Toronto, and Department of Pediatrics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Daniela Dominguez
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Brian M Feldman
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Fangming Liao
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Deborah M Levy
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Lawrence Ng
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Mohamed Abdelhaleem
- M. Abdelhaleem, MBBCh, PhD, FRCPC, Division of Haematopathology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Earl D Silverman
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Linda T Hiraki
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada;
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5
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Poudel P, Swe T, Rayancha S. A Rare Case of Macrophage Activation Syndrome Presenting as the First Manifestation of Systemic Lupus Erythematosus. J Investig Med High Impact Case Rep 2018; 6:2324709618812196. [PMID: 30480003 PMCID: PMC6243398 DOI: 10.1177/2324709618812196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/24/2018] [Accepted: 09/29/2018] [Indexed: 12/18/2022] Open
Abstract
Macrophage activation syndrome (MAS) itself is a rare, potentially life-threatening complication of a rheumatic disease, mostly seen in juvenile idiopathic arthritis. It infrequently occurs in systemic lupus erythematosus (SLE), and it is extremely rare to be the first presentation of SLE. In a study of 511 patients with SLE, 7 cases (1.4%) of MAS were identified. In all the cases, MAS was simultaneous to the presentation of SLE in this article, we report a case of a patient with MAS who presented with fever, rash, and high ferritin level up to 16911 ng/mL. A high degree of suspicion is required that high fever and rash can be clues to MAS. Early diagnosis is necessary since mortality rates remain high for untreated cases.
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Affiliation(s)
- Pooja Poudel
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Thein Swe
- Interfaith Medical Center, New York, NY, USA
| | - Sheetal Rayancha
- State University of New York Upstate Medical University, Syracuse, NY, USA
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6
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Gavand PE, Serio I, Arnaud L, Costedoat-Chalumeau N, Carvelli J, Dossier A, Hinschberger O, Mouthon L, Le Guern V, Korganow AS, Poindron V, Gourguechon C, Lavigne C, Maurier F, Labro G, Heymonet M, Artifoni M, Viau AB, Deligny C, Sene T, Terriou L, Sibilia J, Mathian A, Bloch-Queyrat C, Larroche C, Amoura Z, Martin T. Clinical spectrum and therapeutic management of systemic lupus erythematosus-associated macrophage activation syndrome: A study of 103 episodes in 89 adult patients. Autoimmun Rev 2017; 16:743-749. [PMID: 28483541 DOI: 10.1016/j.autrev.2017.05.010] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 04/16/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Macrophage activation syndrome (MAS) is a life-threatening hyperinflammatory syndrome that can occur during systemic lupus erythematosus (SLE). Data on MAS in adult SLE patients are very limited. The aim of this study is to describe the clinical characteristics, laboratory findings, treatments, and outcomes of a large series of SLE-associated MAS. METHODS We conducted a retrospective study that included 103 episodes of MAS in 89 adult patients with SLE. RESULTS 103 episodes in 89 adult patients were analyzed. Median age at first MAS episode was 32 (18-80) years. MAS was inaugural in 41 patients (46%).Thirteen patients relapsed. Patients had the following features: fever (100% episodes), increased serum levels of AST (94.7%), LDH (92.3%), CRP (84.5%), ferritin (96%), procalcitonin (41/49 cases). Complications included myocarditis (n=22), acute lung injury (n=15) and seizures (n=11). In 33 episodes, patients required hospitalization in an ICU and 5 died. Thrombocytopenia and high CRP levels were associated independently with an increased risk for ICU admission. High dose steroids alone as first line therapy induced remission in 37/57 cases (65%). Additional medications as first or second line therapies included IV immunoglobulins (n=22), cyclophosphamide (n=23), etoposide (n=11), rituximab (n=3). Etoposide and cyclophosphamide-based regimens had the best efficacy. CONCLUSION MAS is a severe complication and is often inaugural. High fever and high levels of AST, LDH, CRP, ferritin and PCT should be considered as red flags for early diagnosis. High dose steroids lead to remission in two third of cases. Cyclophosphamide or etoposide should be considered for uncontrolled/severe forms.
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Affiliation(s)
| | - Ilaria Serio
- Division of Internal Medicine, Department of Medical & Surgical Sciences, University of Bologna, S Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Nathalie Costedoat-Chalumeau
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares, Paris, France; Université Paris Descartes-Sorbonne Paris Cité, Paris, France; INSERM U 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris, Hôpital Cochin, France
| | - Julien Carvelli
- Service de médecine interne et d'immunologie clinique, CHU Conception Marseille - APHM, France
| | - Antoine Dossier
- Service de médecine interne CHU Bichat, Paris, Université paris VII, France
| | | | - Luc Mouthon
- Service de médecine interne, hôpital Cochin, Centre de Référence pour les vascularites nécrosantes et la sclérodermie systémique, DHU Authors (Autoimmune and Hormonal Diseases), Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Véronique Le Guern
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares, Paris, France; Université Paris Descartes-Sorbonne Paris Cité, Paris, France; INSERM U 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris, Hôpital Cochin, France
| | | | - Vincent Poindron
- Service d'immunologie Clinique et médecine interne, CHU de Strasbourg, France
| | | | | | - François Maurier
- Service de médecine Interne et Immunologie Clinique, HP Metz Site Belle Isle, France
| | | | - Marie Heymonet
- CHU de Nancy, Internal Medicine and Clinical immunology Department, France
| | | | | | | | - Thomas Sene
- Service de médecine Interne, Groupe Hospitalier Diaconesses, Croix Saint-Simon, Paris, France
| | - Louis Terriou
- CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France
| | | | - Alexis Mathian
- Service de médecine interne 2, Groupement hospitalier La Pitié-Salpétrière, Paris, France
| | | | | | - Zahir Amoura
- Service de médecine interne 2, Groupement hospitalier La Pitié-Salpétrière, Paris, France
| | - Thierry Martin
- Service d'immunologie Clinique et médecine interne, CHU de Strasbourg, France
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Liu AC, Yang Y, Li MT, Jia Y, Chen S, Ye S, Zeng XZ, Wang Z, Zhao JX, Liu XY, Zhu J, Zhao Y, Zeng XF, Li ZG. Macrophage activation syndrome in systemic lupus erythematosus: a multicenter, case-control study in China. Clin Rheumatol 2017; 37:93-100. [PMID: 28409239 DOI: 10.1007/s10067-017-3625-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 04/03/2017] [Indexed: 01/10/2023]
Abstract
The objective of this study was to describe the clinical and laboratory characteristics, precipitating factors, treatment, and outcome of macrophage activation syndrome (MAS) complicating systemic lupus erythematosus (SLE). A multicenter case-control study was performed across six tertiary hospitals from 1997 to 2014. A total of 32 patients with SLE-associated MAS were enrolled. Sixty-four age- and sex-matched SLE patients diagnosed in the same period without MAS episodes were selected as controls. The most frequent clinical feature was fever, followed by splenomegaly. Hyperferritinemia, hypoalbuminemia, and hyper-lactate dehydrogenase (LDH)-nemia were among the most common laboratory abnormalities. Compared with pre-MAS visit, patients at the onset of MAS had greater frequencies of renal involvement, liver dysfunction, and cytopenia. Receiver operating characteristic (ROC) analysis identified optimal cutoff values of ferritin (>662.5 ng/mL) and LDH (>359 U/mL) to predict the occurrence of MAS in SLE. SLE flare and infection were the common triggers of MAS in SLE. Abortion and parturition were recorded as well. The overall mortality rate was 12.5%. All patients received corticosteroids. Cyclosporine A, cyclophosphamide, and etoposide were the three most commonly used immunosuppressants. Rituximab was given to one patient. Intravenous immunoglobulin (IVIG) was added for 46.9% patients. MAS is a potentially fatal complication of SLE. Its occurrence is most frequently associated with active SLE disease or infection. The presentation of unexplained fever, cytopenia, or liver dysfunction, with high levels of ferritin and LDH, in patients with SLE should raise the suspicion of MAS. Corticosteroids with immunosuppressants and IVIG may be an appropriate treatment.
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Affiliation(s)
- Ai-Chun Liu
- Department of Rheumatology and Immunology, Peking University People's Hospital and Key Laboratory of Rheumatism Mechanism and Immune Diagnosis (BZ0135) and Peking-Tsinghua Center for Life Science, Beijing, China
| | - Yue Yang
- Department of Rheumatology and Immunology, Peking University People's Hospital and Key Laboratory of Rheumatism Mechanism and Immune Diagnosis (BZ0135) and Peking-Tsinghua Center for Life Science, Beijing, China
| | - Meng-Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital and Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
| | - Yuan Jia
- Department of Rheumatology and Immunology, Peking University People's Hospital and Key Laboratory of Rheumatism Mechanism and Immune Diagnosis (BZ0135) and Peking-Tsinghua Center for Life Science, Beijing, China.
| | - Sheng Chen
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Shuang Ye
- Department of Rheumatology and Immunology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Xiang-Zong Zeng
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
| | - Zhao Wang
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
| | - Jin-Xia Zhao
- Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing, China
| | - Xiang-Yuan Liu
- Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing, China
| | - Jian Zhu
- Department of Rheumatology, General Hospital of the People's Liberation Army, Beijing, China
| | - Yan Zhao
- Department of Rheumatology, Peking Union Medical College Hospital and Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Feng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital and Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Zhan-Guo Li
- Department of Rheumatology and Immunology, Peking University People's Hospital and Key Laboratory of Rheumatism Mechanism and Immune Diagnosis (BZ0135) and Peking-Tsinghua Center for Life Science, Beijing, China
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8
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Ruscitti P, Cipriani P, Ciccia F, Masedu F, Liakouli V, Carubbi F, Berardicurti O, Guggino G, Di Benedetto P, Di Bartolomeo S, Valenti M, Triolo G, Giacomelli R. Prognostic factors of macrophage activation syndrome, at the time of diagnosis, in adult patients affected by autoimmune disease: Analysis of 41 cases collected in 2 rheumatologic centers. Autoimmun Rev 2016; 16:16-21. [PMID: 27664384 DOI: 10.1016/j.autrev.2016.09.016] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 07/29/2016] [Indexed: 12/21/2022]
Abstract
Macrophage activation syndrome (MAS) is a rare, life-threatening disease in which early diagnosis and aggressive therapeutic strategy may improve the outcome. Due to its rarity, epidemiologic data are still lacking. Hyperferritinemia is frequently associated with MAS and might modulate the cytokine storm, which is involved in the development of multiple organ failure. In this paper, we investigated clinical data, treatments, and outcome of a homogeneous cohort of 41 adult MAS patients, complicating autoimmune rheumatic diseases. MAS-related death occurred in 17 patients (42.5%) during the follow-up, and older age and increased serum ferritin levels, at the time of diagnosis, were significantly associated with mortality. In conclusion, adult MAS is associated with high mortality rate. Some clinical features at diagnosis may be predictive of MAS-associated death.
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Affiliation(s)
- Piero Ruscitti
- Division of Rheumatology, University of L'Aquila, L'Aquila, Italy
| | - Paola Cipriani
- Division of Rheumatology, University of L'Aquila, L'Aquila, Italy
| | | | - Francesco Masedu
- Division of Medical Statistic Unit, University of L'Aquila, L'Aquila, Italy
| | | | | | | | | | | | | | - Marco Valenti
- Division of Medical Statistic Unit, University of L'Aquila, L'Aquila, Italy
| | - Giovanni Triolo
- Division of Rheumatology, University of Palermo, Palermo, Italy
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Aytaç S, Batu ED, Ünal Ş, Bilginer Y, Çetin M, Tuncer M, Gümrük F, Özen S. Macrophage activation syndrome in children with systemic juvenile idiopathic arthritis and systemic lupus erythematosus. Rheumatol Int 2016; 36:1421-9. [DOI: 10.1007/s00296-016-3545-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 08/02/2016] [Indexed: 01/07/2023]
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10
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Ednalino C, Yip J, Carsons SE. Systematic Review of Diffuse Alveolar Hemorrhage in Systemic Lupus Erythematosus: Focus on Outcome and Therapy. J Clin Rheumatol 2015; 21:305-10. [PMID: 26308350 DOI: 10.1097/RHU.0000000000000291] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is an uncommon but potentially life-threatening manifestation of systemic lupus erythematosus (SLE) associated with high mortality. Although survival and its associated clinical, laboratory, and therapeutic features have been reported for case reports and series, they have not been systematically reviewed. OBJECTIVES The purpose of this systematic review was to assess survival of episodes of DAH in SLE over 3 decades and to categorize trends in therapies, commonly utilized to treat this disorder. RESULTS Overall, SLE patients survived 61% of 174 DAH episodes representing 140 patients. Episode survival was 67% in the time period from 2000 to 2013. Corticosteroids were nearly universally used therapeutically, and cyclophosphamide was used in 55%. Plasmapheresis was used in 31% and did not appear to be associated with survival. CONCLUSIONS Diffuse alveolar hemorrhage in SLE still carries a high risk of mortality; however, survival trends appear to demonstrate an increase from approximately 25% in the 1980s to 67% in the current decade. Increased use of cyclophosphamide appears to be associated with better survival, whereas plasmapheresis does not appear to influence outcome. Although these results need to be interpreted with caution because they are not derived from randomized controlled trials, we believe this represents the largest reported compilation of survival data in DAH associated with SLE.
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Santoriello D, Hogan J, D'Agati VD. Hemophagocytic Syndrome With Histiocytic Glomerulopathy and Intraglomerular Hemophagocytosis. Am J Kidney Dis 2016; 67:978-83. [PMID: 26774467 DOI: 10.1053/j.ajkd.2015.11.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 11/29/2015] [Indexed: 12/12/2022]
Abstract
Hemophagocytic syndrome (HPS), a rare and life-threatening disease, is characterized by hyperactivation of the immune system that causes hypercytokinemia and potential multiorgan failure. Acute kidney injury is the most common kidney manifestation of HPS and is generally considered a poor prognostic factor. Glomerular involvement is uncommon and usually manifests as either podocytopathy with collapsing glomerulopathy or thrombotic microangiopathy. We report a rare case of severe histiocytic glomerulopathy in a patient with HPS who presented with acute kidney injury and proteinuria. Kidney biopsy revealed massive glomerular infiltration by macrophages resembling proliferative glomerulonephritis accompanied by intraglomerular hemophagocytosis and mild features of glomerular thrombotic microangiopathy. The patient's kidney failure and proteinuria responded rapidly to high-dose pulse methylprednisolone followed by a tapering course of oral prednisone. Our case expands the renal pathologic spectrum of HPS to include histiocyte-rich glomerular infiltration and intraglomerular hemophagocytosis. Greater awareness of this entity is needed to ensure prompt recognition and appropriate therapy.
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Affiliation(s)
- Dominick Santoriello
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, NY.
| | - Jonathan Hogan
- Department of Medicine, Division of Nephrology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Vivette D D'Agati
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, NY
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Fleischmann R, Böhmerle W, von Laffert M, Jöhrens K, Mengel A, Hotter B, Lindenberg R, Scheibe F, Köhnlein M, von Bahr Greenwood T, Henter JI, Meisel A. Adult hemophagocytic lymphohistiocytosis causing multi organ dysfunction in a patient with multiple autoimmune disorders: when the immune system runs amok. Clin Case Rep 2015; 4:165-70. [PMID: 26862416 PMCID: PMC4736532 DOI: 10.1002/ccr3.467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 11/05/2015] [Indexed: 12/04/2022] Open
Abstract
We report a case of several autoimmune disorders eventually presenting as severe multi organ dysfunction syndrome caused by adult hemophagocytic lymphohistiocytosis (HLH). Clinical and laboratory tests might lead to fatal misinterpretation without awareness of its diagnostic evaluation, as HLH shares common features with sepsis and immune‐mediated systemic inflammatory response syndromes.
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Affiliation(s)
- Robert Fleischmann
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Wolfgang Böhmerle
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | | | - Korinna Jöhrens
- Department of Pathology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Annerose Mengel
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Benjamin Hotter
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Robert Lindenberg
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Franziska Scheibe
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Martin Köhnlein
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Tatiana von Bahr Greenwood
- Childhood Cancer Research Unit Department of Women׳s and Children׳s Health Karolinska Institutet Karolinska University Hospital Solna 17176 Stockholm Sweden
| | - Jan Inge Henter
- Childhood Cancer Research Unit Department of Women׳s and Children׳s Health Karolinska Institutet Karolinska University Hospital Solna 17176 Stockholm Sweden
| | - Andreas Meisel
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
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Granata G, Didona D, Stifano G, Feola A, Granata M. Macrophage Activation Syndrome as Onset of Systemic Lupus Erythematosus: A Case Report and a Review of the Literature. Case Rep Med 2015; 2015:294041. [PMID: 26064125 DOI: 10.1155/2015/294041] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 04/23/2015] [Indexed: 11/23/2022] Open
Abstract
Macrophage activation syndrome (MAS) is a potentially fatal condition. It belongs to the hemophagocytic lymphohistiocytosis group of diseases. In adults, MAS is rarely associated with systemic lupus erythematosus, but it also arises as complication of several systemic autoimmune disorders, like ankylosing spondylitis, rheumatoid arthritis, and adult-onset Still's disease. Several treatment options for MAS have been reported in the literature, including a therapeutic regimen of etoposide, dexamethasone, and cyclosporine. Here we report a case of 42-year-old woman in whom MAS occurred as onset of systemic lupus erythematosus.
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Ono A, Kawasaki Y, Kanno S, Ohara S, Sakai N, Suyama K, Hosoya M. A case of a child with sle presenting with hps as a primary manifestation. Fukushima J Med Sci 2015; 60:181-6. [PMID: 25747608 DOI: 10.5387/fms.2013-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The primary manifestations of systemic lupus erythematosus (SLE) are various. One such manifestation is hemophagocytic syndrome (HPS). We here report a child with SLE presenting with HPS as a primary manifestation. In October 2010, an 11-year-old Japanese boy presented with pancytopenia, elevated liver enzymes, hyperferritinemia and hemophagocytosis due to macrophages in the bone marrow, and was diagnosed with HPS. A year later, he was found to have proteinuria and hematuria. Oral aphtha and Raynaud's phenomenon were observed, and the patient showed low serum complement levels and was positive for anti-nuclear antibodies (ANAs). He was subsequently diagnosed with SLE. Moreover, low serum complement levels and ANA positivity were detected in a serum sample preserved at the onset of HPS. The HPS was considered to be a primary manifestation of SLE on the basis of these findings. Based on this case, the presence of an underlying disease, such as SLE, should be investigated in cases of HPS.
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Affiliation(s)
- Atsushi Ono
- Department of Pediatrics, Fukushima Medical University School of Medicine
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15
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Lim E, Kim YG, Choi WS, Jung YS, Han JH, Bae CB, Jung JY, Kim HA, Suh CH. Three Cases of Secondary Hemophagocytic Lymphohistiocytosis Associated with Systemic Erythematosus Lupus. J Rheum Dis 2015. [DOI: 10.4078/jrd.2015.22.3.180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Eunsoo Lim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Young-Geon Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Won-Sun Choi
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Yu-Soek Jung
- Department of Laboratory Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Jae-Ho Han
- Department of Pathology, Ajou University School of Medicine, Suwon, Korea
| | - Chang-Bum Bae
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Ju-Yang Jung
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
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Takahashi H, Tsuboi H, Kurata I, Takahashi H, Inoue S, Ebe H, Yokosawa M, Hagiwara S, Hirota T, Asashima H, Kaneko S, Kawaguchi H, Kurashima Y, Miki H, Umeda N, Kondo Y, Ogishima H, Suzuki T, Matsumoto I, Sumida T. Predictors of the response to treatment in acute lupus hemophagocytic syndrome. Lupus 2014; 24:659-68. [PMID: 25391543 DOI: 10.1177/0961203314559086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 10/16/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objective of this paper is to identify predictors for the response to treatment of acute lupus hemophagocytic syndrome (ALHS). METHODS We reviewed seven cases with ALHS admitted to our hospital and published ALHS cases identified in the 2001-2014 Medline database, and then conducted univariate and multivariate analyses to identify predictors for the response to treatment. RESULTS Review of our cases showed a significant and negative correlation between serum ferritin and anti-DNA antibody (p = 0.0025). All three patients treated with cyclosporine A (CsA) were considered responders despite high serum ferritin and corticosteroid resistance. We also reviewed 93 patients with ALHS identified in 46 articles. Multiple logistic regression analysis identified C-reactive protein (CRP) (OR 0.83, p = 0.042) and hemoglobin (OR 1.53, p = 0.026) measured at diagnosis of ALHS as significant predictors of the response to corticosteroid monotherapy. Moreover, among 32 patients treated with CsA, serum ferritin was significantly higher in CsA responders (12163 ± 16864 µg/l, n = 22) than in non-responders (3456 ± 6267/µg/l, p = 0.020, n = 10). Leukocyte count was significantly lower in the CsA responders (1940.0 ± 972.3/µl) than in the non-responders (3253 ± 2198/µl, p = 0.034). CONCLUSION Low CRP and high hemoglobin can predict a positive response to corticosteroid monotherapy while high serum ferritin and low leukocyte count can predict a positive response to CsA in patients with ALHS and therefore, when corticosteroid monotherapy is not effective in such cases, CsA could be the first choice of an additional immunosuppressive agent.
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Affiliation(s)
- H Takahashi
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - H Tsuboi
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - I Kurata
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - H Takahashi
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - S Inoue
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - H Ebe
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - M Yokosawa
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - S Hagiwara
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - T Hirota
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - H Asashima
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - S Kaneko
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - H Kawaguchi
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Y Kurashima
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - H Miki
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - N Umeda
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Y Kondo
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - H Ogishima
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - T Suzuki
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - I Matsumoto
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - T Sumida
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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Ueda Y, Yamashita H, Takahashi Y, Kaneko H, Kano T, Mimori A. Refractory hemophagocytic syndrome in systemic lupus erythematosus successfully treated with intermittent intravenous cyclophosphamide: three case reports and literature review. Clin Rheumatol 2013; 33:281-6. [DOI: 10.1007/s10067-013-2451-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 11/24/2013] [Indexed: 11/25/2022]
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Torres Jiménez A, Solís Vallejo E, Zeferino Cruz M, Céspedes Cruz A, Sánchez Jara B. Macrophage activation syndrome as the initial manifestation of severe juvenile onset systemic lupus erythematosus. Favorable response to cyclophosphamide. ACTA ACUST UNITED AC 2013; 10:331-5. [PMID: 24035795 DOI: 10.1016/j.reuma.2013.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 05/23/2013] [Accepted: 05/28/2013] [Indexed: 12/11/2022]
Abstract
The macrophage activation syndrome is a rare but potentially fatal complication of patients with autoimmune rheumatic diseases. This is a clinicopathological entity characterized by activation of histiocytes with prominent hemophagocytosis in the bone marrow and other reticuloendothelial systems. In patients with lupus it may mimic an exacerbation of the disease or infection. We report the case of a 7-year-old girl in whom the diagnosis of lupus erythematosus and macrophage activation syndrome was simultaneously made with response to the use of cyclophosphamide.
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Affiliation(s)
- Alfonso Torres Jiménez
- Reumatología Pediátrica, Hospital General Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, México D.F., México.
| | - Eunice Solís Vallejo
- Reumatología Pediátrica, Hospital General Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, México D.F., México
| | - Maritza Zeferino Cruz
- Reumatología Pediátrica, Hospital General Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, México D.F., México
| | - Adriana Céspedes Cruz
- Reumatología Pediátrica, Hospital General Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, México D.F., México
| | - Berenice Sánchez Jara
- Hematología Pediátrica, Hospital General Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, México D.F., México
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Catoggio C, Alvarez-Uría A, Fernandez PL, Cervera R, Espinosa G. Catastrophic antiphospholipid syndrome triggered by fulminant disseminated herpes simplex infection in a patient with systemic lupus erythematosus. Lupus 2012; 21:1359-61. [DOI: 10.1177/0961203312458841] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Infections are considered one of the most common causes of morbidity and mortality in patients with systemic lupus erythematosus (SLE), and occasionally can trigger a catastrophic antiphospholipid syndrome (APS). We describe a 22-year-old SLE patient with lupus nephritis under immunosuppressant therapy and asymptomatic carrier of antiphospholipid antibodies, who was admitted with tonsillitis and acute hepatitis, developing multiorgan failure in a few hours. Postmortem examination revealed hepatic necrosis, tonsillitis, pharyngitis and uterine cervicitis caused by herpes simplex virus (HSV) together with microthrombosis in lungs and glomerular arterioles, suggesting the diagnosis of fulminant HSV disseminated infection and catastrophic APS.
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Affiliation(s)
- C Catoggio
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - A Alvarez-Uría
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - PL Fernandez
- Department of Pathology, Hospital Clínic, Barcelona, Spain
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - G Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
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20
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Kim JM, Kwok SK, Ju JH, Kim HY, Park SH. Reactive hemophagocytic syndrome in adult Korean patients with systemic lupus erythematosus: a case-control study and literature review. J Rheumatol 2011; 39:86-93. [PMID: 22174206 DOI: 10.3899/jrheum.110639] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To determine the characteristics of hemophagocytic syndrome (HPS) in adult Korean patients with systemic lupus erythematosus (SLE). METHODS We reviewed the medical records of 1033 adult patients with SLE for a recent 14-year period and identified 15 patients who had developed HPS. Forty-two age- and sex-matched patients with SLE admitted for other manifestations were included as disease controls. Features of HPS in these patients were analyzed. RESULTS Reactive HPS occurred from some distinct causes during the course of SLE. HPS was associated with SLE in 11 patients (4 at onset of SLE and 7 at SLE flare), infection in 3 patients (2 bacterial infection; 1 viral infection), and drug use (azathioprine) in 1 patient. Common clinical features included fever (93.3%), hepatomegaly (60.0%), and splenomegaly (60.0%). Steroid pulse therapy (46.7%), immunosuppressants (46.7%), and intravenous immunoglobulin (46.7%) were frequently used for treatment of HPS. One patient (6.7%) died. Compared with SLE patients without HPS, those with HPS showed a higher SLEDAI score (p = 0.003) and lower levels of plasma leukocytes (p < 0.001), hemoglobin (p = 0.013), and platelets (p < 0.001) as well as a higher serum C-reactive protein level (p = 0.039) and a lower serum albumin level (p = 0.004). CONCLUSION HPS was observed in 1.5% of adult Korean patients with SLE. The occurrence of HPS was most frequently associated with the SLE disease activity. Profound pancytopenia, a high SLEDAI score, and notable changes in the level of acute-phase reactants can be the characteristics of SLE patients with HPS.
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Affiliation(s)
- Ji-Min Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 505, Banpo-dong, Seocho-gu, Seoul, 137-040, Republic of Korea
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Yamamura K, Ohga S, Nishiyama K, Doi T, Tsutsumi Y, Ikeda K, Fujishima A, Takada H, Hara T. Recurrent atrial fibrillation after high-dose methylprednisolone therapy in a girl with lupus-associated hemophagocytic syndrome. Lupus 2011; 20:871-5. [DOI: 10.1177/0961203310392429] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hemophagocytic syndrome (HPS) is a serious complication of systemic lupus erythematosus (SLE). A 15-year-old female with lupus-nephritis developed HPS. Bone marrow study showed florid thrombophagocytosis. There was no associated infection. High-dose methylprednisolone therapy ameliorated HPS. However, atrial fibrillation (Af) repeated after the infusion and required direct-current cardioversion. No underlying diseases were found in the heart and endocrine system. Chest roentgenogram and echocardiography were normal. Electrocardiogram showed slightly prolonged PR interval in sinus rhythm. Af occurred at high circulating levels of interferon-γ and interleukin (IL)-10, but not IL-6, IL-2, tumor necrosis factor-α, C-reactive protein or catecholamines. This is the first observation that high-dose corticosteroid induced Af in a case of lupus-HPS. Af is unusual in SLE children without cardiac disease, while conduction defect occurs associated with lupus-myocarditis. Lupus-HPS may be an aggressive SLE subset with cardiac involvement. High-dose corticosteroid infusion controls lupus activity, but could disclose the cardiac stress in lupus-HPS patients.
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Affiliation(s)
- K Yamamura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - S Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - K Nishiyama
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T Doi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Y Tsutsumi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - K Ikeda
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - A Fujishima
- Division of Clinical Laboratories, Kyushu University Hospital, Fukuoka, Japan
| | - H Takada
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T Hara
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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