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La T, Ansari S, Ha E, Novakovic M. Systemic Lupus Erythematosus and Lupus Nephritis Presenting as Severe Constitutional Symptoms. Cureus 2024; 16:e56670. [PMID: 38646266 PMCID: PMC11032414 DOI: 10.7759/cureus.56670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 04/23/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is a remitting-relapsing systemic autoantibody and immune complex disease with a similar clinical presentation to that of malignancy and infection. The authors report a case of newly diagnosed SLE and lupus nephritis in a 48-year-old woman with constitutional symptoms and unintentional weight loss. Her presentation was further complicated by pericardial effusion and methicillin-resistant Staphylococcus aureus (MRSA) facial cellulitis and bacteremia. In the context of nonspecific symptoms and a wide initial differential diagnosis, the early consideration of rheumatologic etiologies and the involvement of consultant services led to appropriate diagnostic testing and a timely diagnosis.
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Affiliation(s)
- Ton La
- Internal Medicine, Baylor College of Medicine, Houston, USA
| | - Sahifah Ansari
- Internal Medicine, Baylor College of Medicine, Houston, USA
| | - Ethan Ha
- Internal Medicine, University of Texas Medical Branch, Galveston, USA
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2
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Kerkar AS, Bhagwat SN, Sharma JH. A Study of Clinical and Serological Correlation of Positive Direct Antiglobulin Test in Blood Bank at a Tertiary Care Center. J Lab Physicians 2022; 14:223-230. [PMID: 36119425 PMCID: PMC9473924 DOI: 10.1055/s-0041-1741442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives
Detection of red cell bound immunoglobulins and/or complement by direct antiglobulin test (DAT) is a crucial serological assay in the diagnosis of autoimmune hemolytic anemia (AIHA). However, DAT may be positive in a variety of clinical conditions with or without hemolysis. We aimed at evaluating the clinical and serological correlation of positive DAT by categorizing the clinical conditions associated with positive DAT, estimating the presence of in vivo hemolysis in case of positive DAT with polyspecific and monospecific antisera and correlating the strength of positive DAT with the presence of hemolysis.
Materials and Methods
The prospective observational study was performed on 200 samples that were positive for DAT with polyspecific antiglobulin reagent as the baseline investigation. These samples were further tested with anti-immunoglobulin G and anti-C3 monospecific DAT reagents to evaluate the type of protein responsible for positive DAT. The antiglobulin tests were performed by tube technique. DAT positivity was graded (1+ to 4 + ) in each patient. Autocontrol test was included. The patients with positive polyspecific DAT were categorized into different clinical conditions. The presence or absence of in vivo hemolysis was evaluated in all clinical categories and also for each grade of positivity with polyspecific and monospecific antiglobulin reagents.
Statistical Analysis
Binomial logistic regression and Mann–Whitney
U
test were applied to between the group analyses. For categorical variables, Fisher's exact test and relative risk were used. The qualitative data were expressed in numbers and percentages.
Results
The highest number of patients (75/200, 37.5%) belonged to the autoimmune diseases group. Tuberculosis and hepatitis C were the main infectious diseases associated with positive DAT. Out of 200 DAT-positive patients, 98 (49%) had in vivo hemolysis and 102 (51%) did not have hemolysis. AIHA (22) and systemic lupus erythematosus (18) were the commonest clinical conditions associated with in vivo hemolysis. All the 11 samples that showed positivity with only anti-C3 reagent did not show any hemolysis. There was statistically significant increase in the incidence of in vivo hemolysis with increasing grades of DAT positivity with all the three antihuman globulin reagents.
Conclusion
There are different disease conditions which show positive DAT with or without hemolysis. So, it is important to clinically and serologically correlate positive DAT results.
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Affiliation(s)
- Alisha Suresh Kerkar
- Department of Transfusion Medicine, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Swarupa Nikhil Bhagwat
- Department of Transfusion Medicine, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Jayashree Harihara Sharma
- Department of Transfusion Medicine, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Akca ÜK, Batu ED, Kısaarslan AP, Poyrazoğlu H, Ayaz NA, Sözeri B, Sağ E, Atalay E, Demir S, Karadağ ŞG, Demir F, Bilginer Y, Gümrük F, Özen S. Hematological involvement in pediatric systemic lupus erythematosus: A multi-center study. Lupus 2021; 30:1983-1990. [PMID: 34459313 DOI: 10.1177/09612033211038824] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Systemic lupus erythematosus (SLE) may present with features of several systems, including hematological manifestations. In this study, we aimed to evaluate the characteristics of hematological involvement and assess possible associations and correlations in pediatric SLE patients. Method: This is a retrospective multi-center study. The medical records of pediatric SLE patients followed between January 2000 and June 2020 were analyzed. All children fulfilled the criteria of the Systemic Lupus International Collaborating Clinics. Results: The study included 215 children with SLE, 118 of whom had hematological manifestations. Concomitant renal involvement and low C3 levels were significantly more frequent in patients with hematological involvement (p = 0.04, p = 0.008, respectively). Also, anti-cardiolipin, anti-beta-2-glycoprotein I (anti-β2 GP1), and anti-Sm antibody positivity, and the presence of lupus anticoagulant were more common in the group with hematological findings (p = 0.001 for anti-cardiolipin antibody positivity and p < 0.001 for the positivity of anti-β2 GP1 antibody, anti-Sm antibody, and lupus anticoagulant). The most common hematologic abnormality was anemia (n = 88, 74.5%), with autoimmune hemolytic anemia constituting the majority (n = 40). Corticosteroids followed by IVIG were the mainstay of treatment. In patients resistant to corticosteroid and IVIG treatments, the most preferred drug was rituximab. Low levels of C3, high SLEDAI score, high incidence of renal involvement, and positive antiphospholipid antibodies were associated with hematological involvement in the univariate analysis. The presence of antiphospholipid antibodies and high SLEDAI score were independently associated with hematological involvement in multivariate analysis (OR: 4.021; 95% CI: 2.041-7.921; p < 0.001 and OR: 1.136; 95% CI: 1.065-1.212; p < 0.001). Conclusion: Hematological abnormalities are frequently encountered in pediatric SLE. Positive antiphospholipid antibodies and high SLEDAI scores were associated with hematological involvement.
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Affiliation(s)
- Ümmüşen Kaya Akca
- Department of Pediatrics, Division of Rheumatology, 37515Hacettepe University64005Faculty of Medicine, Ankara, Turkey
| | - Ezgi Deniz Batu
- Department of Pediatrics, Division of Rheumatology, 37515Hacettepe University64005Faculty of Medicine, Ankara, Turkey
| | - Ayşenur Pac Kısaarslan
- Department of Pediatrics, Division of Rheumatology, 64212Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Hakan Poyrazoğlu
- Department of Pediatrics, Division of Rheumatology, 64212Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Nuray Aktay Ayaz
- Department of Pediatrics, Division of Rheumatology, 64041Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Betül Sözeri
- Department of Pediatrics, Division of Rheumatology, 64041Umraniye Training and Research Center, University of Health Sciences, Istanbul, Turkey
| | - Erdal Sağ
- Department of Pediatrics, Division of Rheumatology, 37515Hacettepe University64005Faculty of Medicine, Ankara, Turkey
| | - Erdal Atalay
- Department of Pediatrics, Division of Rheumatology, 37515Hacettepe University64005Faculty of Medicine, Ankara, Turkey
| | - Selcan Demir
- Department of Pediatrics, Division of Rheumatology, 37515Hacettepe University64005Faculty of Medicine, Ankara, Turkey
| | - Şerife Gül Karadağ
- Department of Pediatrics, Division of Rheumatology, 64041Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ferhat Demir
- Department of Pediatrics, Division of Rheumatology, 64041Umraniye Training and Research Center, University of Health Sciences, Istanbul, Turkey
| | - Yelda Bilginer
- Department of Pediatrics, Division of Rheumatology, 37515Hacettepe University64005Faculty of Medicine, Ankara, Turkey
| | - Fatma Gümrük
- Department of Pediatrics, Division of Hematology, 37515Hacettepe University64005Faculty of Medicine, Ankara, Turkey
| | - Seza Özen
- Department of Pediatrics, Division of Rheumatology, 37515Hacettepe University64005Faculty of Medicine, Ankara, Turkey
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Caielli S, Cardenas J, de Jesus AA, Baisch J, Walters L, Blanck JP, Balasubramanian P, Stagnar C, Ohouo M, Hong S, Nassi L, Stewart K, Fuller J, Gu J, Banchereau JF, Wright T, Goldbach-Mansky R, Pascual V. Erythroid mitochondrial retention triggers myeloid-dependent type I interferon in human SLE. Cell 2021; 184:4464-4479.e19. [PMID: 34384544 PMCID: PMC8380737 DOI: 10.1016/j.cell.2021.07.021] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/05/2021] [Accepted: 07/19/2021] [Indexed: 02/08/2023]
Abstract
Emerging evidence supports that mitochondrial dysfunction contributes to systemic lupus erythematosus (SLE) pathogenesis. Here we show that programmed mitochondrial removal, a hallmark of mammalian erythropoiesis, is defective in SLE. Specifically, we demonstrate that during human erythroid cell maturation, a hypoxia-inducible factor (HIF)-mediated metabolic switch is responsible for the activation of the ubiquitin-proteasome system (UPS), which precedes and is necessary for the autophagic removal of mitochondria. A defect in this pathway leads to accumulation of red blood cells (RBCs) carrying mitochondria (Mito+ RBCs) in SLE patients and in correlation with disease activity. Antibody-mediated internalization of Mito+ RBCs induces type I interferon (IFN) production through activation of cGAS in macrophages. Accordingly, SLE patients carrying both Mito+ RBCs and opsonizing antibodies display the highest levels of blood IFN-stimulated gene (ISG) signatures, a distinctive feature of SLE.
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Affiliation(s)
- Simone Caielli
- Drukier Institute for Children's Health, Weill Cornell Medicine, New York, NY, USA; Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA.
| | | | - Adriana Almeida de Jesus
- Translational Autoinflammatory Diseases Section, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Jeanine Baisch
- Drukier Institute for Children's Health, Weill Cornell Medicine, New York, NY, USA; Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | | | | | - Preetha Balasubramanian
- Drukier Institute for Children's Health, Weill Cornell Medicine, New York, NY, USA; Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Cristy Stagnar
- Drukier Institute for Children's Health, Weill Cornell Medicine, New York, NY, USA; Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Marina Ohouo
- Drukier Institute for Children's Health, Weill Cornell Medicine, New York, NY, USA; Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Seunghee Hong
- Drukier Institute for Children's Health, Weill Cornell Medicine, New York, NY, USA; Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Lorien Nassi
- Texas Scottish Rite Hospital for Children, Dallas, TX, USA; Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Katie Stewart
- Texas Scottish Rite Hospital for Children, Dallas, TX, USA; Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Julie Fuller
- Texas Scottish Rite Hospital for Children, Dallas, TX, USA; Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jinghua Gu
- Drukier Institute for Children's Health, Weill Cornell Medicine, New York, NY, USA; Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | | | - Tracey Wright
- Texas Scottish Rite Hospital for Children, Dallas, TX, USA; Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Raphaela Goldbach-Mansky
- Translational Autoinflammatory Diseases Section, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Virginia Pascual
- Drukier Institute for Children's Health, Weill Cornell Medicine, New York, NY, USA; Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA.
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Antiphospholipid Antibodies and Autoimmune Haemolytic Anaemia: A Systematic Review and Meta-Analysis. Int J Mol Sci 2020; 21:ijms21114120. [PMID: 32527000 PMCID: PMC7313475 DOI: 10.3390/ijms21114120] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 02/02/2023] Open
Abstract
The relationship between antiphospholipid antibodies (aPL) and autoimmune haemolytic anaemia (AIHA) has never been systematically addressed. The aim of this study is to assess the link between aPL and AIHA in adult systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). This study performed an EMBASE/PubMed search from inception to June 2019 and meta-analysis using Peto’s odds ratios. The pooled prevalence (PP) of IgG/IgM anticardiolipin (aCL) and lupus anticoagulant (LA) was greater in AIHA +ve than AIHA −ve patients (34.7% vs. 27.6%, p = 0.03; 33.3% vs. 21.8%, p < 0.0001; 20.9% vs. 8.3%, p = 0.01). The PP of AIHA was greater in: (1) IgG and IgM aCL +ve than −ve patients (21.8% vs. 11.1%, p = 0.001 and 18.7% vs. 6.3%, p < 0.0001), (2) in SLE related APS than in primary APS patients (22.8% vs. 3.9% p < 0.0001), (3) in APS +ve than APS −ve SLE patients (23.2% vs. 8.4%, p = 0.01), and (4) in thrombotic APS than non-thrombotic APS/SLE patients (26.8% vs. 10%, p = 0.03). The PP of IgG/IgM aCL and LA was greater in DAT +ve than DAT −ve patients (42.4% vs. 12.8%, p < 0.0001; 26.2% vs. 12.8%, p = 0.03 and 29.2% vs. 15.7%, p = 0.004 respectively). It was found that AIHA prevalence is maximal in SLE with aPL/APS, low-moderate in SLE without aPL and minimal in PAPS. Moreover, AIHA is rightly included among the classification criteria for SLE but not for APS/aPL. The significance of an isolated DAT positivity remains unclear in this setting
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A Case with Purine Nucleoside Phosphorylase Deficiency Suffering from Late-Onset Systemic Lupus Erythematosus and Lymphoma. J Clin Immunol 2020; 40:833-839. [DOI: 10.1007/s10875-020-00800-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/28/2020] [Indexed: 11/25/2022]
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7
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Bouw MC, Nij Bijvank SWA, Bouwhuis JW, van Wezel-Meijler G. Fetal Intraventricular Hemorrhage Due to Antiphospholipid Syndrome: A Case Report. Front Pediatr 2020; 8:622597. [PMID: 33614545 PMCID: PMC7894573 DOI: 10.3389/fped.2020.622597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/17/2020] [Indexed: 11/13/2022] Open
Abstract
Obstetric Antiphospholipid Syndrome (OAPS) is an autoimmune disease characterized by certain pregnancy complications in association with persistent antiphospholipid antibodies. These antibodies are generally known for their prothrombotic characteristics and may affect mother and fetus during the entire pregnancy. The clinical criteria for OAPS, including recurrent fetal loss, intra-uterine growth restriction and premature birth due to severe preeclampsia, all suggest uteroplacental vascular insufficiency. Although rare, thrombotic complications have been described in neonates born to mothers with OAPS, mainly ischemic stroke. We report on the first case of extensive fetal intraventricular hemorrhage related to OAPS. We share our diagnostic search and analysis for this unusual antenatal event, including cranial ultrasound findings and postmortem MRI images. We will also present a short review of the etiology and prognosis of antenatal intraventricular hemorrhage. We suggest that women with severe or early preeclampsia and/or a history of pregnancy loss should be evaluated for OAPS and carefully monitored throughout pregnancy. Further, we advise to test mothers for OAPS in the case of idiopathic fetal hemorrhage.
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Affiliation(s)
- M C Bouw
- Department of Neonatology, Isala Women and Children's Hospital, Zwolle, Netherlands
| | - S W A Nij Bijvank
- Department of Obstetrics and Gynecology, Isala Women and Children's Hospital, Zwolle, Netherlands
| | - J W Bouwhuis
- Department of Internal Medicine, Isala Hospital, Zwolle, Netherlands
| | - G van Wezel-Meijler
- Department of Neonatology, Isala Women and Children's Hospital, Zwolle, Netherlands
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