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Xiao PB, Yang XR. Anti-SSA/Ro antibody-positive autoimmune myocarditis combined with complete atrioventricular block requiring implantation with a permanent pacemaker: A case report. World J Clin Cases 2025; 13:104283. [DOI: 10.12998/wjcc.v13.i22.104283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2024] [Revised: 03/28/2025] [Accepted: 04/14/2025] [Indexed: 05/14/2025] Open
Abstract
BACKGROUND Autoimmune myocarditis (AM) associated with autoimmune diseases can cause complete atrioventricular block (CAVB), but the related autoantigens and the underlying mechanisms are unclear. Anti-SSA/Ro antibodies may play an important role in this process, but cases of AM with positive anti-SSA/Ro antibodies are rare. In addition, arrhythmias, such as atrioventricular block, are very common in patients with autoimmune diseases, but severe atrioventricular block requiring permanent pacemaker implantation is extremely rare.
CASE SUMMARY The patient in this case had AM with anti-SSA/Ro antibody positivity, which was associated with connective tissue disease, and the patient subsequently developed CAVB. After intensive immunosuppressive therapy, the antibody test results became negative, and pulmonary hypertension significantly improved. However, the outcome of permanent pacemaker implantation did not change.
CONCLUSION In clinical practice, the awareness of adult AM associated with autoimmune diseases combined with CAVB should be strengthened in clinicians, and anti-SSA/Ro antibodies may play a role in this process. Therefore, improving the detection of antibodies and early intervention, such as active immunosuppression therapy, may be very important for improving disease prognosis. For patients who do not respond to immunosuppressive therapy, implantation of a permanent pacemaker may become an essential treatment option.
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Affiliation(s)
- Peng-Bo Xiao
- Department of Rheumatology and Immunology, Shengli Oilfield Central Hospital, Dongying 257034, Shandong Province, China
| | - Xi-Rui Yang
- Department of Rheumatology and Immunology, Shengli Oilfield Central Hospital, Dongying 257034, Shandong Province, China
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2
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Rojas-Cadena M, Rodríguez-Arcentales F, Narváez-Cajas J, Arias-Intriago M, Morales Orbe K, Izquierdo-Condoy JS. Myopericarditis and Pericardial Effusion as the Initial Presentation of Systemic Lupus Erythematosus in a Patient with Sickle Cell Trait: A Case Report. J Clin Med 2025; 14:920. [PMID: 39941591 PMCID: PMC11818129 DOI: 10.3390/jcm14030920] [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] [Received: 01/10/2025] [Revised: 01/23/2025] [Accepted: 01/27/2025] [Indexed: 02/16/2025] Open
Abstract
Background: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with rare but severe cardiac manifestations, including myocarditis and pericarditis. The coexistence of SLE with sickle cell trait (SCT), an inherited hemoglobinopathy prevalent among individuals of African descent, is exceptionally rare and presents significant diagnostic challenges due to overlapping clinical features. Objective: To describe the case of an Afro-Ecuadorian male with SLE and sickle cell trait who developed an uncommon presentation of myopericarditis and pericardial effusion. Case report: A 48-year-old African American male with no prior medical history presented with persistent fever, polyarticular arthralgias, and pleuritic chest pain. Investigations revealed sickle cell trait (SCT) and myopericarditis with pericardial effusion, marking the initial manifestation of SLE. Diagnostic delays occurred due to overlapping symptoms and a family history of sickle cell disease. Laboratory findings showed elevated hemoglobin S (<50%), positive ANA (1:1280, coarse speckled pattern), and anti-Smith/RNP antibodies, meeting EULAR/ACR 2019 criteria for SLE. Cardiac MRI confirmed myopericarditis. Treatment with pulse methylprednisolone, oral prednisone, and mycophenolate mofetil resulted in clinical improvement, with stable disease control on immunomodulatory therapy during follow-up. Conclusions: This case highlights the diagnostic complexity of SLE in patients with SCT, particularly when presenting with myopericarditis as the initial manifestation. It emphasizes the importance of a comprehensive diagnostic approach and timely initiation of immunosuppressive therapy to optimize clinical outcomes. This report broadens the understanding of overlapping syndromes involving SLE and SCT.
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Affiliation(s)
- Marlon Rojas-Cadena
- Medical Science Faculty, Universidad Católica del Ecuador, Quito 170525, Ecuador
| | | | - Jose Narváez-Cajas
- Medical Science Faculty, Universidad Católica del Ecuador, Quito 170525, Ecuador
| | - Marlon Arias-Intriago
- Department Section of Histology, Faculty of Medical Science, Universidad Central del Ecuador, Quito 170402, Ecuador
| | - Karen Morales Orbe
- One Health Research Group, Universidad de las Américas, Quito 170521, Ecuador
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3
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Fesharaki MJ, Dehkordi NR, Zakeri Z, Hosseinjani E, Dehkordi NR. A rare case of systemic lupus erythematosus presenting with concurrent myocarditis, central retinal vein occlusion, and deep vein thrombosis. Clin Case Rep 2024; 12:e9520. [PMID: 39493795 PMCID: PMC11527729 DOI: 10.1002/ccr3.9520] [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] [Received: 05/08/2024] [Revised: 09/13/2024] [Accepted: 09/14/2024] [Indexed: 11/05/2024] Open
Abstract
Although systemic lupus erythematosus may present with broad and variable symptoms, the rare and atypical combined presentation of central retinal vein occlusion, myocarditis, and deep vein thrombosis poses a diagnostic challenge and highlights the need for a comprehensive diagnostic approach. Early diagnosis and prompt treatment help mitigate disease morbidity and mortality, and emphasize the importance of heightened clinical suspicion in complex presentations.
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Affiliation(s)
- Mehrdad Jafari Fesharaki
- Department of Cardiology, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | - Negar Raissi Dehkordi
- Department of Cardiology, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
- Cardiovascular Research Center, Shahid Labbafinezhad HospitalShahid Beheshti University of Medical SciencesTehranIran
| | - Zahra Zakeri
- Department of Adult Rheumatology, School of Medicine, Shahid Labbafinezhad HospitalShahid Beheshti University of Medical SciencesTehranIran
| | - Emadoddin Hosseinjani
- Department of Cardiology, School of Medicine, Cardiovascular Research CenterShahid Labbafinezhad Hospital
| | - Nastaran Raissi Dehkordi
- Cardiovascular Research Center, Shahid Labbafinezhad HospitalShahid Beheshti University of Medical SciencesTehranIran
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4
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Won T, Song EJ, Kalinoski HM, Moslehi JJ, Čiháková D. Autoimmune Myocarditis, Old Dogs and New Tricks. Circ Res 2024; 134:1767-1790. [PMID: 38843292 DOI: 10.1161/circresaha.124.323816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/08/2024] [Indexed: 06/12/2024]
Abstract
Autoimmunity significantly contributes to the pathogenesis of myocarditis, underscored by its increased frequency in autoimmune diseases such as systemic lupus erythematosus and polymyositis. Even in cases of myocarditis caused by viral infections, dysregulated immune responses contribute to pathogenesis. However, whether triggered by existing autoimmune conditions or viral infections, the precise antigens and immunologic pathways driving myocarditis remain incompletely understood. The emergence of myocarditis associated with immune checkpoint inhibitor therapy, commonly used for treating cancer, has afforded an opportunity to understand autoimmune mechanisms in myocarditis, with autoreactive T cells specific for cardiac myosin playing a pivotal role. Despite their self-antigen recognition, cardiac myosin-specific T cells can be present in healthy individuals due to bypassing the thymic selection stage. In recent studies, novel modalities in suppressing the activity of pathogenic T cells including cardiac myosin-specific T cells have proven effective in treating autoimmune myocarditis. This review offers an overview of the current understanding of heart antigens, autoantibodies, and immune cells as the autoimmune mechanisms underlying various forms of myocarditis, along with the latest updates on clinical management and prospects for future research.
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Affiliation(s)
- Taejoon Won
- Department of Pathobiology, College of Veterinary Medicine, University of Illinois Urbana-Champaign (T.W.)
| | - Evelyn J Song
- Section of Cardio-Oncology and Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco (E.J.S., J.J.M.)
| | - Hannah M Kalinoski
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD (H.M.K., D.Č)
| | - Javid J Moslehi
- Section of Cardio-Oncology and Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco (E.J.S., J.J.M.)
| | - Daniela Čiháková
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD (H.M.K., D.Č)
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD (D.Č)
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5
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Ovaga BE, Zahri S, Mulendele P, Huda A, Bennani G, Charif H, Abbassi I, Haboub M, Drighil A, Habbal R. [Tableau d'insuffisance cardiaque congestive révélant une myocardite lupique : cas clinique]. Ann Cardiol Angeiol (Paris) 2024; 73:101720. [PMID: 38301591 DOI: 10.1016/j.ancard.2023.101720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 11/28/2023] [Accepted: 12/07/2023] [Indexed: 02/03/2024]
Abstract
Systemic lupus erythematosus (SLE or lupus) is a disease in which the immune system attacks healthy cells and tissues throughout the body. Lupus myocarditis is a life-threatening condition, observed clinically in 3-9 % of patients with SLE. We report the case of a patient followed for multisystem SLE, presenting with de novo heart failure with severe left ventricular dysfunction revealing lupus myocarditis.
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Affiliation(s)
- B E Ovaga
- Département de Cardiologie, Centre hospitalier universitaire IBN ROCHD, Casablanca, Maroc.
| | - S Zahri
- Département de Cardiologie, Centre hospitalier universitaire IBN ROCHD, Casablanca, Maroc.
| | - P Mulendele
- Département de Cardiologie, Centre hospitalier universitaire IBN ROCHD, Casablanca, Maroc.
| | - A Huda
- Département de Cardiologie, Centre hospitalier universitaire IBN ROCHD, Casablanca, Maroc.
| | - G Bennani
- Département de Cardiologie, Centre hospitalier universitaire IBN ROCHD, Casablanca, Maroc
| | - H Charif
- Département de Cardiologie, Centre hospitalier universitaire IBN ROCHD, Casablanca, Maroc
| | - I Abbassi
- Département de Cardiologie, Centre hospitalier universitaire IBN ROCHD, Casablanca, Maroc
| | - M Haboub
- Département de Cardiologie, Centre hospitalier universitaire IBN ROCHD, Casablanca, Maroc
| | - A Drighil
- Département de Cardiologie, Centre hospitalier universitaire IBN ROCHD, Casablanca, Maroc
| | - R Habbal
- Département de Cardiologie, Centre hospitalier universitaire IBN ROCHD, Casablanca, Maroc
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Santos A, Kure C, Sanchez C, Gross P. The Diagnostic Dilemma of "The Great Imitator": Heart and Cerebral Involvement of Lupus Manifesting as Bilateral Upper and Lower Extremity Weakness. Case Rep Rheumatol 2023; 2023:6676357. [PMID: 37854887 PMCID: PMC10581839 DOI: 10.1155/2023/6676357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 10/20/2023] Open
Abstract
Background Systemic lupus erythematous (SLE) is an autoimmune condition which can cause complex, multiorgan dysfunction. This autoimmune disease is caused by the production of antinuclear antibodies which allows this disease to target virtually any organ in the human body. When a patient experiences an unpredictable worsening of disease activity, it is generally considered a lupus flare. Organ dysfunction due to a lupus flare tends to manifest as separate events in the literature and rarely do we witness multiple compounding organ failures during a lupus flare. If we do witness organ dysfunction and failure, rarely do we see cardiac and cerebral involvement. Typically, patients take immunosuppressants for a long term to avoid the patient's disease process from worsening and to provide prophylaxis from a flare to occur. Despite the availability in preventive strategies, some patients will have increased disease activity multiple times throughout their lifetime and will need increases in their medication doses or changes to their regimen. Some flares can be managed in the clinic, but more severe ones may be life-threatening that they require intravenous medications and hospitalization to achieve remission. In the following case, we see a patient with a past medical history of SLE on multiple immunosuppressants who arrived at the hospital with acute, bilateral weakness of the upper and lower extremities. It was later determined via various imaging and laboratory testing that she was having an SLE flare that was directly causing myocarditis which progressed to global ischemia of the brain via myocardial hypoperfusion. She experienced substantial recovery from her flare with treatment with high-dose, intravenous corticosteroids. Case Report. A 27-year-old female with a 2-year history of lupus and a 1-week history of paroxysmal atrial fibrillation presented with three days of bilateral focal neurological deficits in the arms and legs. She was found to have ischemic cardiac and neurologic manifestations during her hospital stay. Conclusion Our patient presented with reversible focal neurological deficits, elevated high-sensitive troponin levels, and high lupus serum antibodies who showed significant improvement after the introduction of high-dose steroids. This case recommends keeping a large differential and to not discount patients' past comorbidities for causing atypical symptomatology.
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Affiliation(s)
| | - Catrina Kure
- Northeast Georgia Medical Center, Gainesville, USA
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Allaoui A, El Ouarradi A, Jabbouri R, Naitelhou A. Mycophenolate Mofetil Use in Severe Myocarditis Complicating Systemic Lupus. Cureus 2022; 14:e25789. [PMID: 35812561 PMCID: PMC9270891 DOI: 10.7759/cureus.25789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 11/23/2022] Open
Abstract
Cardiac involvement represents an increasingly frequent complication in systemic lupus, with pericarditis being the most classic cardiac manifestation. However, the most severe and fatal form seems to be myocarditis. We present the case of a patient with systemic lupus complicated by cardiogenic shock secondary to troponin-negative acute myopericarditis and successfully treated with mycophenolate mofetil and corticosteroid therapy. A 33-year-old woman with no past medical history presented with asthenia and inflammatory arthralgia. She was admitted in June 2021 for acute heart failure. Transthoracic cardiac ultrasound showed dilated cardiomyopathy with global hypokinesis (20-25% of ejection fraction) and right ventricular dysfunction without significant mitral and aortic valve disease. She had raised proBNP (pro-brain natriuretic peptide), low troponin, normochromic normocytic anemia at 10.4 g/dL, positive direct Coombs, lymphopenia at 460/mm3, serum creatinine at 23.9 mg/L, and proteinuria/creatininuria 2.48 g/g. Cardiac magnetic resonance imaging (CMR) suggested the diagnosis of myopericarditis. The etiological assessment did not identify an infectious, toxic, or medicinal cause. The clinical picture suggested the possibility of an autoimmune disease. The patient presented with lesions suggestive of cutaneous vasculitis, with oral ulcers with polyarthritis. The autoimmune workup showed anti-nuclear antibodies at 1:1,280, anti-native DNA antibodies at 210 IU/mL (normal < 10 IU/mL), and positive anti-SM Abs. The diagnosis of lupus myopericarditis complicated by cardiogenic shock was made, which was associated with acute renal impairment. The patient was initiated on heart failure medications along with corticosteroids and mycophenolate mofetil. On day 15, the left ventricular ejection fraction improved to 45-50%, with clinical improvement in signs of heart failure and general condition. The existence of myopericarditis without obvious etiology, especially when there are extra-cardiac signs such as skin and joint involvement, should lead us to look for systemic lupus in order to start etiological treatment in addition to cardiac medical treatment. Until now, there is no standard treatment for lupus myocarditis, but the use of mycophenolate mofetil seems to be a promising treatment.
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Affiliation(s)
- Abire Allaoui
- Internal Medicine, Mohammed VI University of Health Sciences (UM6SS), Casablanca, MAR
- Internal Medicine, Cheikh Khalifa International University Hospital, Casablanca, MAR
- Laboratory of Clinical Immunology, Inflammation and Allergy, Faculty of Medicine and Pharmacy of Casablanca, Hassan II University of Casablanca, Casablanca, MAR
| | - Amal El Ouarradi
- Cardiology, Mohammed VI University of Health Sciences (UM6SS), Casablanca, MAR
- Cardiology, Mohammed VI International University Hospital, Casablanca, MAR
| | - Rajaa Jabbouri
- Internal Medicine, Mohammed VI University of Health Sciences (UM6SS), Casablanca, MAR
- Internal Medicine, Cheikh Khalifa International University Hospital, Casablanca, MAR
| | - Abdelhamid Naitelhou
- Internal Medicine, Mohammed VI University of Health Sciences (UM6SS), Casablanca, MAR
- Internal Medicine, Cheikh khalifa International University Hospital, Casablanca, MAR
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Mohanty B, Sunder A. Lupus myocarditis-A rare case. J Family Med Prim Care 2020; 9:4441-4443. [PMID: 33110880 PMCID: PMC7586557 DOI: 10.4103/jfmpc.jfmpc_716_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/11/2020] [Accepted: 07/01/2020] [Indexed: 11/13/2022] Open
Abstract
Myocarditis in patients of systemic lupus erythematosus is extremely rare and is potentially life threatening. This may be the first presentation of the disease. Here, we report a patient who presented with features of heart failure and was later diagnosed to have SLE.
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Affiliation(s)
- Bijaya Mohanty
- Department of Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India
| | - Ashok Sunder
- Department of Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India
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9
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Xing ZX, Yu K, Yang H, Liu GY, Chen N, Wang Y, Chen M. Successful use of plasma exchange in fulminant lupus myocarditis coexisting with pneumonia: A case report. World J Clin Cases 2020; 8:2056-2065. [PMID: 32518801 PMCID: PMC7262706 DOI: 10.12998/wjcc.v8.i10.2056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/21/2020] [Accepted: 04/17/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Fulminant lupus myocarditis is a rare but fatal manifestation of systemic lupus erythematosus. Aggressive immunosuppressive treatments are important in its successful management. However, they can significantly damage the immunity and are associated with a considerable risk of infection development and spread. We present a rare and complicated case of a 20-year-old female diagnosed with fulminant lupus myocarditis accompanied by pneumonia. The patient was successfully treated with plasma exchange (PE) for fulminant lupus myocarditis.
CASE SUMMARY A 20-year-old Chinese woman presented to the Hematology Department complaining of fatigue and knee pain. Blood test showed anemia and thrombocytopenia. On the second day of hospitalization, she was transferred to the ICU due to dyspnea and hypotension. Autoimmune profiles showed hypocomplementemia and positive antinuclear antibodies. Computer tomography showed an enlarged heart and pneumonia. Ultrasound revealed an enlarged heart with a low left ventricular ejection fraction. Fulminant lupus myocarditis with cardiogenic shock was initially considered. Due to the accompanying pneumonia, aggressive immunosuppression was contraindicated. Her cardiac function remained critical after the initial therapy of intravenous immunoglobulin and corticosteroids at a conventional dose, but she responded well to later PE therapy plus corticosteroids administration. The patient fully recovered with normal cardiac function.
CONCLUSION This case indicates that PE is a valuable treatment choice without adverse effects of immunosuppression in patients with fulminant lupus myocarditis and coexisting infection.
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Affiliation(s)
- Zhou-Xiong Xing
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Kun Yu
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Hang Yang
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Guo-Yue Liu
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Ni Chen
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Yong Wang
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Miao Chen
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
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