Adult-Onset Still's Disease: Still a Serious Health Problem (a Case Report and Literature Review)

The diagnostic dilemma of adult-onset Still's disease: a case report

Introduction and importance

Adult-onset Still's disease (AOSD) is a rare auto-inflammatory disorder, characterized by high-grade fever, arthritis, and a variety of systemic signs/symptoms. AOSD is very often misdiagnosed because of the overlapping clinical features, necessitating a thorough differential diagnosis, especially in cases of fever of unknown origin (FUO).

Case presentation

A 55-year-old male with high-grade fever, myalgia, and arthralgia for the past 4 weeks. Yamaguchi criteria for AOSD met following an extensive evaluation. Laboratory findings showed leukocytosis with neutrophilic predominance, elevated ferritin levels, and mild abnormalities in liver function tests. The patient was started on intravenous corticosteroids, followed by oral corticosteroids in tapering dose of the drug and the introduction of methotrexate as a steroid-sparing agent (DMARDs).

Clinical discussion

The case illustrates the diagnostic challenges associated with AOSD in older persons and the importance to consider this condition in the context of a FUO. The diagnosis of AOSD remains exclusive, yet effective management typically involves corticosteroids and DMARDs.

Conclusion

AOSD, though rare, can occur uncommonly in older populations. This case highlights the need for awareness among clinicians to ensure early diagnosis and appropriate management, ultimately aiding in better outcomes of patient.

Adult-Onset Still's Disease and Pulmonary Embolism: A Case Report

Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder characterized by fever, rash, arthralgia, and systemic inflammation. Pulmonary embolism (PE), a potentially life-threatening complication, is infrequently associated with AOSD. This report presents a unique case that highlights the importance of considering atypical presentations of PE in this patient population despite the absence of classical risk factors. An 84-year-old male with hypertension, benign prostatic hypertrophy, and AOSD diagnosed six years prior, presented with confusion, fever, and malaise for two days. He denied any recent travel or immobilization. Examination revealed tachycardia and reduced oxygen saturation on room air. D-dimer was elevated, and CT chest angiography (CTCA) confirmed left upper and lower segmental PE without cardiac strain. Investigations for infection were negative. Initial treatment with intravenous heparin was switched to apixaban. The patient was eventually discharged home with stable vital signs. The inflammatory state in AOSD might contribute to hypercoagulability, increasing the risk of PE. This case emphasizes the importance of considering PE in AOSD patients, even in the absence of classical risk factors, to prevent potentially fatal complications. A literature review revealed few cases of AOSD presenting with PE, highlighting the atypical presentation and need for increased awareness. This case underscores the rare, but potentially serious, association between AOSD and unprovoked PE. Clinicians managing AOSD should maintain a high index of suspicion for PE, particularly in patients presenting with unexplained respiratory symptoms.

Hemophagocytic lymphohistiocytosis accompanying Still's disease: A case report

Hemophagocytic lymphohistiocytosis (HLH) is a rare hematologic disease that occurs due to immune system dysfunction. Clinical manifestations of this disease are fever, increased ferritin level, cytopenia, and hemophagocytosis in the biopsy report of the bone marrow. We report a 36-year-old woman referred to our hospital with persistent fever, arthralgia in interphalangeal joints, and cutaneous rash on the trunk, was subsequently diagnosed as an adult-onset Still's disease (AOSD), and after bone marrow aspiration, HLH was diagnosed with her.

Adult-Onset Still's Disease: A Case Report

Adult-onset Still's disease (AOSD) is a disorder that is occasionally seen. Autoinflammation is a generally accepted pathogenic mechanism leading to systemic signs and symptoms. We report the case of a young female presenting with high-grade fever, rash, and arthralgias. After a thorough assessment, the diagnosis of adult-onset Still's disease was made based on presenting symptoms and elevated serum ferritin, c-reactive protein (CRP), and absence of serologic markers and confirmed based on Yamaguchi criteria. She was treated with corticosteroids and achieved complete clinical remission.

An Unusual Presentation of Adult-Onset Still's Disease as Hemophagocytic Lymphohistiocytosis in a Male Patient

Hemophagocytic lymphohistiocytosis (HLH) is an aggressive and potentially fatal condition characterized by immune activation and multi-organ dysfunction. HLH can be inherited in an autosomal recessive fashion, but can also be secondary to infections, malignancy, immunosuppression, and autoimmune conditions. Adult-onset Still’s disease (AOSD) is an autoimmune disorder that can predispose patients to HLH. AOSD, similar to other autoimmune conditions, is more common in females than males. However, the occurrence of AOSD in males and subsequent predisposition to HLH is rarely reported. We report the case of a 23-year-old male patient who presented with fever, joint pain, and rash for 20 days. On evaluation, he fulfilled the diagnostic criteria for AOSD and HLH, and a diagnosis of HLH secondary to AOSD was made. He was treated with pulse dose steroids and gradually tapered. AOSD and HLH have overlapping clinical and laboratory features and hence their co-occurrence poses diagnostic challenges. The mortality rate of HLH is high and hence prompt initiation of treatment is of utmost importance.

Adult Onset Still´s Disease (AOSD): A rare condition with a classic presentation. Case Report

Introduction: Adult Onset Still´s Disease (AOSD) is a rare systemic inflammatory disease of unclear etiology, with low incidence and prevalence among the general population. AOSD is a common cause of fever of unknown origin (FUO) in up to 20% of cases. Due to the scarce knowledge about this disease and its diagnosis, it is usually unrecognized in the differential diagnoses, worsening the prognosis and increasing complications in some patients.Case presentation: This is the case of a 32-year-old female patient with prolonged febrile illness, who did not respond to the antimicrobial treatments previously established. She was diagnosed with AOSD according to the Yamaguchi criteria after an extensive exclusion process. She was treated with first-line treatment with corticosteroids, achieving satisfactory results.Conclusions: The diagnosis of AOSD is an exhaustive process. Regardless of the availability of cutting-edge diagnostic tools, the medical history of the patient and an adequate physical examination are the most important aspects to consider.

Genetic Association and Expression Correlation between Colony-Stimulating Factor 1 Gene Encoding M-CSF and Adult-Onset Still's Disease

Adult-onset Still's disease (AOSD) is a rare and inflammatory disorder characterized by spiking fever, rash, arthritis, and multisystemic involvement. HLA has been shown to be associated with AOSD; however, it could not explain the innate immunity and autoinflammatory characteristics of AOSD. To assess the genetic susceptibility of AOSD, we conducted a genome-wide association study (GWAS) on a cohort of 70 AOSD cases and 688 controls following a replication study of 36 cases and 200 controls and meta-analysis. The plasma concentrations of associated gene product were determined. The GWAS, replication, and combined sample analysis confirmed that SNP rs11102024 on 5'-upstream of CSF1 encoding macrophage colony-stimulating factor (M-CSF) was associated with AOSD (P = 1.20 × 10^-8, OR (95% CI): 3.28 (2.25~4.79)). Plasma levels of M-CSF increased in AOSD patients (n = 82, median: 9.31 pg/mL), particularly in the cases with activity score ≥ 6 (n = 42, 10.94 pg/mL), compared to the healthy donors (n = 68, 5.31 pg/mL) (P < 0.0001). Patients carrying rs11102024TT genotype had higher M-CSF levels (median: 20.28 pg/mL) than those with AA genotype (6.82 pg/mL) (P < 0.0001) or AT genotype (11.61 pg/mL) (P = 0.027). Patients with systemic pattern outcome were associated with elevated M-CSF and frequently observed in TT carriers. Our data suggest that genetic variants near CSF1 are associated with AOSD and the rs11102024 T allele links to higher M-CSF levels and systemic outcome. These results provide a promising initiative for the early intervention and therapeutic target of AOSD. Further investigation is needed to have better understandings and the clinical implementation of genetic variants nearby CSF1 in AOSD.

Macrophage activation syndrome associated with adult-onset Still's disease: a multicenter retrospective analysis

OBJECTIVES

To explore the clinical features, treatments, and prognostic factors of adult-onset Still's disease (AOSD)-associated macrophage activation syndrome (MAS), we conducted a multicenter retrospective clinical study of AOSD-associated MAS patients.

METHODS

AOSD patients were collected from six tertiary hospitals in China. Medical charts were reviewed and clinical information was recorded and analyzed.

RESULTS

There were 447 AOSD patients enrolled into this retrospective clinical study. Among them, 55 were diagnosed with MAS. Liver dysfunction was the most reliable predictive factor for the screening of MAS in AOSD patients (OR = 75.744, 95%CI = 23.015-249.284, p < 0.0001). In multivariate analysis, clinical features including platelets < 100 × 10⁹/L (OR = 9.546, p = 0.005), aspartate transaminase (AST) > 120 U/L (OR = 25.853, p < 0.0001), triglycerides > 3 mmol/L (OR = 12.9833, p = 0.011)), ferritin > 1500 ng/mL (OR = 5.513, p = 0.050), as well as hemophagocytosis in bone puncture (OR = 18.132, p = 0.001) were highly associated with the occurrence of MAS. The mortality rate of total AOSD patients was 4.47%, MAS was the main cause of death in AOSD patients (OR = 11.705, 95%CI = 4.783-28.647, p < 0.0001). PLT ≤ 100 × 10⁹/L (p = 0.0001), fibrinogen < 1.5 g/L (p = 0.0286), splenomegaly (p = 0.0002), and liver dysfunction (p = 0.0008) highly suggested poor prognosis.

CONCLUSION

MAS occurrence is the major cause of death in AOSD patients. Notable liver dysfunction, as well as splenomegaly, low number of platelets or neutrophils, high levels of serum ferritin, and reduced level of fibrinogen are risk factors for poor outcome. Key Points • This is a multicenter retrospective study of AOSD-associated MAS with large number of cases.

Molecular genetic analysis for periodic fever syndromes: a supplemental role for the diagnosis of adult-onset Still's disease

Adult-onset Still's disease (AOSD) represents a systemic autoinflammatory disease (SAID), and its diagnostic criteria are clinical without genetic testing. Given shared manifestations between AOSD and hereditary SAIDs, molecular analysis may help differentiate these diseases. A PubMed literature search was conducted using key words "adult-onset Still's disease," "autoinflammatory disease," and "genetic mutation" between 1970 and February 2018. Articles on genetic mutations in the genes MEFV, TNFRSF1A, mevalonate kinase, or NOD2 for hereditary SAIDs in AOSD/systemic onset juvenile idiopathic arthritis (SJIA) patients were reviewed and analyzed. Five case series studies consisting of a total of 162 of both adult and pediatric patients were included. All patients fulfilled the Yamaguchi criteria for AOSD or the diagnostic criteria for SJIA. The results showed that 31.4% (51/162) of patients were identified to carry at least one genetic variant for periodic fever syndromes. In addition, four patients with the diagnosis of SJIA in other reports were confirmed to have FMF or TRAPS with molecular testing. These data together suggest that some patients who satisfy the clinical diagnostic criteria for AOSD/SOJIA could well be diagnosed with other SAIDs; genetic testing, particularly for those with atypical presentation can be supplementary to the accurate disease diagnosis by excluding other autoinflammatory diseases. AOSD is a diagnosis of exclusion and shares common manifestations with other SAIDs. The currently employed clinical criteria for AOSD can cause misdiagnosis. An updated set of classification criteria to integrate the molecular genetic analysis to exclude other autoinflammatory diseases is warranted.

Severe Adult-onset Still Disease with Constrictive Pericarditis and Pleuritis That Was Successfully Treated with Tocilizumab in Addition to Corticosteroids and Cyclosporin A

Adult-onset Still disease (AOSD) is a systemic inflammatory disease characterized by fever, arthritis and rash. Corticosteroids represent a promising therapeutic option for AOSD; however, some resistant cases require immunosuppressants and biologic agents. We herein report the case of a 29-year-old Japanese man with severe AOSD, accompanied by constrictive pericarditis (CP) and pleuritis. Although 2 courses of steroid pulse and subsequent high-dose of prednisolone and cyclosporine A improved the patient's CP and pleuritis, his fever and inflammatory responses persisted. Tocilizumab (TCZ) was added to his treatment, which resulted in a rapid remission. This case suggests the usefulness of TCZ in the treatment of severe AOSD with CP and pleuritis.