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Iwasaki T, Mizusaki K, Masumoto M, Minagawa Y, Azuma K, Furukawa T, Yoshida M, Kuragano T. TAFRO syndrome with renal biopsy successfully treated with steroids and cyclosporine: a case report. BMC Nephrol 2022; 23:262. [PMID: 35870879 PMCID: PMC9308189 DOI: 10.1186/s12882-022-02886-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 07/13/2022] [Indexed: 12/27/2022] Open
Abstract
Abstract
Background
TAFRO syndrome is an acute or subacute systemic inflammatory disease with no apparent cause, presenting with fever, generalized edema, thrombocytopenia, renal damage, anemia, and organ enlargement. Interleukin-6, vascular endothelial growth factor, and other cytokines are thought to be the etiologic agents that increase vascular permeability and cause the resulting organ damage. Only few reports of renal biopsy performed in patients with TAFRO syndrome exist.
Case presentation
A 61-year-old woman, with a history of Sjogren’s syndrome, was admitted to our hospital with anasarca and abdominal distension. Based on the clinical course and various laboratory findings, we diagnosed TAFRO syndrome. Renal biopsy revealed thrombotic microangiopathy, including endothelial cell swelling, subendothelial space expansion, and mesangiolysis. She was treated with oral prednisolone and cyclosporine, with consequent resolution of anasarca, pleural effusion, and ascites, and improvement in renal function and urinary findings. The patient’s platelet count also normalized after 2 months of treatment.
Conclusions
Given that only few reports of improvement in the systemic symptoms of TAFRO syndrome using steroids and cyclosporine exist, our study investigating the relationship between the pathogenesis of TAFRO syndrome and renal disorders, as well as treatment methods, provides valuable insights.
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Grange L, Chalayer E, Boutboul D, Paul S, Galicier L, Gramont B, Killian M. TAFRO syndrome: A severe manifestation of Sjogren's syndrome? A systematic review. Autoimmun Rev 2022; 21:103137. [PMID: 35803499 DOI: 10.1016/j.autrev.2022.103137] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sjögren's syndrome (SjS) is a systemic autoimmune disease characterized by lymphocytic infiltration of the salivary and lacrimal glands associated with sicca syndrome. TAFRO syndrome is a systemic inflammatory disease of unknown cause, characterized by Thrombocytopenia, Anasarca, Fever, Reticulin fibrosis, Renal dysfunction and Organomegaly, first reported in 2010 in Japanese patients. Despite their rarity, both conditions have been concurrently reported in several patients during the recent years, hence questioning the existence of shared or related features. METHODS A systematic review of the literature regarding SjS associated with TAFRO syndrome (SjS-TAFRO) was performed. The 2019 updated Masaki diagnostic criteria were used for TAFRO syndrome and SjS was considered when the diagnosis was mentioned by the authors, necessarily with either anti-Sjogren's Syndrome A (SSA) ± anti-Sjogren's Syndrome B (SSB) antibodies and/or histological evidence of focal lymphocytic sialadenitis. RESULTS Ten cases of SjS-TAFRO have been reported in the literature to date. Compared to SjS patients without TAFRO syndrome, these 10 SjS-TAFRO had a lower female predominance (2.3:1 vs 9:1 women to man ratio) and a higher frequency of anti-SSA antibodies (90% vs 70%). All fulfilled the three major Masaki criteria i.e., anasarca, thrombocytopenia, and systemic inflammation. Seven of them (70%) had megakaryocyte hyperplasia or reticulin fibrosis in the bone marrow. Lymph node biopsy was performed in 8 out of 10 cases (80%) and results were consistent with Castleman disease in 6 (75%). Eight of them had developed renal failure (80%) within six months. Nine of them (90%) had organomegaly, with hepatosplenomegaly in 8 cases and splenomegaly alone in 1. CONCLUSION This review brings new insights regarding TAFRO syndrome and suggests it could be a severe manifestation of SjS. The identification of shared abnormal signaling pathways could help in the therapeutic management of both diseases, which face an unmet therapeutic need.
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Affiliation(s)
- Lucile Grange
- Department of Internal Medicine, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Emilie Chalayer
- Department of Hematology and Cell Therapy, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France; Inserm U1059-SAINBIOSE, dysfonction vasculaire et hémostase, Université de Lyon, Saint-Etienne, France
| | - David Boutboul
- Clinical Immunology Department, Hôpital Saint Louis, Université Paris Cité, Paris, France; National Reference Center for Castleman disease, Hôpital Saint Louis, Université Paris Cité, Paris, France; U976 HIPI, INSIGHT Team, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Stéphane Paul
- Department of Immunology, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France; CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université Jean Monnet, Unversité Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, F42023 Saint-Etienne, France; CIC 1408 Inserm, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Lionel Galicier
- Clinical Immunology Department, Hôpital Saint Louis, Université Paris Cité, Paris, France; National Reference Center for Castleman disease, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Baptiste Gramont
- Department of Internal Medicine, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France; CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université Jean Monnet, Unversité Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, F42023 Saint-Etienne, France
| | - Martin Killian
- Department of Internal Medicine, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France; CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université Jean Monnet, Unversité Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, F42023 Saint-Etienne, France; CIC 1408 Inserm, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France.
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Nishimura Y, Nishimura MF, Sato Y. International definition of iMCD-TAFRO: future perspectives. J Clin Exp Hematop 2022; 62:73-78. [PMID: 35474036 PMCID: PMC9353848 DOI: 10.3960/jslrt.21037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Since thrombocytopenia, anasarca, fever, reticulin fibrosis, renal insufficiency, and organomegaly (TAFRO) syndrome was first proposed in 2010, there has been considerable progress in this area, particularly regarding its association with idiopathic multicentric Castleman disease (iMCD). TAFRO syndrome is a heterogeneous category with a constellation of symptoms that can develop in the setting of infection, rheumatologic disorder, malignancy, and iMCD. Now, iMCD with TAFRO symptoms is subtyped as iMCD-TAFRO. However, confusion between TAFRO syndrome and iMCD-TAFRO remains. In this article, we discuss the current understanding and future research agenda of TAFRO syndrome and iMCD-TAFRO from the perspective of its new validated international definition.
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Affiliation(s)
- Yoshito Nishimura
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.,Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Midori Filiz Nishimura
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuharu Sato
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
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Nishimura Y, Nishikori A, Sawada H, Czech T, Otsuka Y, Nishimura MF, Mizuno H, Sawa N, Momose S, Ohsawa K, Otsuka F, Sato Y. Idiopathic multicentric Castleman disease with positive antiphospholipid antibody: atypical and undiagnosed autoimmune disease? J Clin Exp Hematop 2022; 62:99-105. [PMID: 35249898 PMCID: PMC9353850 DOI: 10.3960/jslrt.21038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Idiopathic multicentric Castleman disease (iMCD) is a systemic disorder characterized by systemic inflammation and organ dysfunction associated with an increase in pro-inflammatory cytokines. Some patients with iMCD are positive for autoantibodies, although their significance and relationship with specific associated autoimmune diseases are unclear. This study retrospectively analyzed the clinicopathological features of iMCD patients focusing on autoantibodies. Among 63 iMCD patients in our database, 19 were positive for at least one autoantibody. Among the 19, we identified five with plasma cell type (PC)-iMCD lymph node histopathology and positive anti-phospholipid antibodies. These patients were likely to have thrombocytopenia, anasarca, fever, reticulin fibrosis or renal insufficiency, organomegaly (TAFRO) symptoms, and thrombotic events. The present study suggests that patients with undiagnosed or atypical autoimmune diseases, including anti-phospholipid syndrome (APS), were treated for iMCD. APS may present with thrombocytopenia or even multi-organ failure, which overlap with clinical presentations of iMCD. Due to differences in the treatment regimen and follow-up, recognition of the undiagnosed autoimmune disease process in those suspected of iMCD is essential. Our study highlights the importance of complete exclusion of differential diagnoses in patients with iMCD in their diagnostic workup.
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Affiliation(s)
- Yoshito Nishimura
- Department of Medicine, University of Hawaii, Honolulu, HI, USA.,Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Asami Nishikori
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Haruki Sawada
- Department of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Torrey Czech
- Department of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Yuki Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Midori Filiz Nishimura
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroki Mizuno
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Naoki Sawa
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Shuji Momose
- Department of Pathology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Kumiko Ohsawa
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan.,Department of Pathology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Fumio Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuharu Sato
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan.,Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Nishimura Y, Fajgenbaum DC, Pierson SK, Iwaki N, Nishikori A, Kawano M, Nakamura N, Izutsu K, Takeuchi K, Nishimura MF, Maeda Y, Otsuka F, Yoshizaki K, Oksenhendler E, Rhee F, Sato Y. Validated international definition of the thrombocytopenia, anasarca, fever, reticulin fibrosis, renal insufficiency, and organomegaly clinical subtype (TAFRO) of idiopathic multicentric Castleman disease. Am J Hematol 2021; 96:1241-1252. [PMID: 34265103 DOI: 10.1002/ajh.26292] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/03/2021] [Accepted: 07/10/2021] [Indexed: 12/11/2022]
Abstract
Thrombocytopenia, anasarca, fever, reticulin fibrosis, renal insufficiency, and organomegaly (TAFRO) syndrome is a heterogeneous entity manifesting with a constellation of symptoms described above that can occur in the context of idiopathic multicentric Castleman disease (iMCD) as well as infectious diseases, malignancies, and rheumatologic disorders. So, iMCD-TAFRO is an aggressive subtype of iMCD with TAFRO syndrome and often hyper-vascularized lymph nodes. Since we proposed diagnostic criteria of iMCD-TAFRO in 2016, we have accumulated new insights on the disorder and additional cases have been reported worldwide. In this systematic review and cohort analysis, we established and validated a definition for iMCD-TAFRO. First, we searched PubMed and Japan Medical Abstracts Society databases using the keyword "TAFRO" to extract cases. Patients with possible systemic autoimmune diseases and hematologic malignancies were excluded. Our search identified 54 cases from 50 articles. We classified cases into three categories: (1) iMCD-TAFRO (TAFRO syndrome with lymph node histopathology consistent with iMCD), (2) possible iMCD-TAFRO (TAFRO syndrome with no lymph node biopsy performed and no other co-morbidities), and (3) TAFRO without iMCD or other co-morbidities (TAFRO syndrome with lymph node histopathology not consistent with iMCD or other comorbidities). Based on the findings, we propose an international definition requiring four clinical criteria (thrombocytopenia, anasarca, fever/hyperinflammatory status, organomegaly), renal dysfunction or characteristic bone marrow findings, and lymph node features consistent with iMCD. The definition was validated with an external cohort (the ACCELERATE Natural History Registry). The present international definition will facilitate a more precise and comprehensive approach to the diagnosis of iMCD-TAFRO.
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Affiliation(s)
- Yoshito Nishimura
- Department of General Medicine Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama Japan
- Department of Medicine John A. Burns School of Medicine, University of Hawai'i Honolulu Hawaii USA
| | - David C. Fajgenbaum
- Center for Cytokine Storm Treatment & Laboratory, Division of Translational Medicine and Human Genetics Perelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
| | - Sheila K. Pierson
- Center for Cytokine Storm Treatment & Laboratory, Division of Translational Medicine and Human Genetics Perelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
| | - Noriko Iwaki
- Hematology/Respiratory Medicine Kanazawa University Graduate School of Medical Science Kanazawa Japan
| | - Asami Nishikori
- Division of Pathophysiology Okayama University Graduate School of Health Sciences Okayama Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology Kanazawa University Graduate School of Medical Science Kanazawa Japan
| | - Naoya Nakamura
- Department of Pathology Tokai University School of Medicine Isehara Japan
| | - Koji Izutsu
- Department of Hematology National Cancer Center Hospital Tokyo Japan
| | - Kengo Takeuchi
- Department of Pathology The Cancer Institute Hospital of Japanese Foundation for Cancer Research Tokyo Japan
- Division of Pathology Cancer Institute, Japanese Foundation for Cancer Research Tokyo Japan
- Pathology Project for Molecular Targets Cancer Institute, Japanese Foundation for Cancer Research Tokyo Japan
| | - Midori Filiz Nishimura
- Department of Pathology Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama Japan
| | - Yoshinobu Maeda
- Department of Hematology Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Fumio Otsuka
- Department of General Medicine Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama Japan
| | - Kazuyuki Yoshizaki
- Department of Organic Fine Chemicals Institute of Scientific and Industrial Research, Osaka University Osaka Japan
| | - Eric Oksenhendler
- Department of Clinical Immunology Hôpital Saint‐Louis Paris France
- Université de Paris Paris France
| | - Frits Rhee
- Myeloma Center University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Yasuharu Sato
- Division of Pathophysiology Okayama University Graduate School of Health Sciences Okayama Japan
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Kadoba K, Waki D, Nishimura K, Mukoyama H, Saito R, Murabe H, Yokota T. Development of severe thrombocytopenia with TAFRO syndrome-like features in a patient with rheumatoid arthritis treated with a Janus kinase inhibitor: A case report. Medicine (Baltimore) 2020; 99:e22793. [PMID: 33080751 PMCID: PMC7571883 DOI: 10.1097/md.0000000000022793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Thrombocytepenia, anasarca, fever, renal insufficiency, and organomegaly (TAFRO) syndrome is a novel disease entity characterized by a constellation of symptoms (thrombocytopenia, anasarca, fever, renal insufficiency, and organomegaly). Here, we describe the development of TAFRO syndrome-like features during the treatment of rheumatoid arthritis with a Janus kinase (JAK) inhibitor. PATIENT CONCERNS In this report, a 74-year-old woman treated with a JAK inhibitor (tofacitinib) for rheumatoid arthritis was admitted because of fever and thrombocytopenia. DIAGNOSES On laboratory examination, marked thrombocytopenia and elevated creatinine and C-reactive protein levels were present. A computed tomography scan revealed lymphadenopathy, hepato-splenomegaly, and anasarca. A left axillary lymph node biopsy revealed Castleman's disease-like features. These clinical features satisfied the proposed diagnostic criteria for TAFRO syndrome. Since autoimmune disorders should be excluded when diagnosing TAFRO syndrome, it is not strictly correct to diagnose her as TAFRO syndrome. Therefore, we diagnosed her as rheumatoid arthritis complicated by TAFRO syndrome-like features. INTERVENTIONS The patient was treated with high-dose glucocorticoid, tacrolimus, eltrombopag, intravenous immunoglobulin, and rituximab. OUTCOMES Her condition was refractory to the above-mentioned treatment, and she eventually died because of multi-organ failure 6 months after the first admission. LESSONS TAFRO syndrome-like features can develop during treatment with a JAK inhibitor for rheumatoid arthritis. Patients with autoimmune diseases complicated by TAFRO syndrome-like features can follow a fatal clinical course, and thus, an intensive combined treatment is warranted for such patients, especially in cases refractory to glucocorticoid.
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Primary Sjögren's Syndrome Accompanied by Clinical Features of TAFRO Syndrome. Case Rep Rheumatol 2020; 2020:8872774. [PMID: 33014503 PMCID: PMC7519461 DOI: 10.1155/2020/8872774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/26/2020] [Accepted: 08/31/2020] [Indexed: 12/31/2022] Open
Abstract
Sjögren's syndrome (SS) is associated with not only sicca symptoms but also various symptoms caused by extraglandular manifestation. The pathophysiology and comorbidities of TAFRO syndrome (thrombocytopenia, anasarca, fever, reticulin fibrosis, and organomegaly), which is thought to be a variant of multicentric Castleman's disease, are not fully understood, and there are few data on the effectiveness of treatments. We report a patient of SS with TAFRO syndrome-like clinical features. A 52-year-old woman was admitted to our hospital because of abdominal distension. Laboratory data showed thrombocytopenia, and image findings showed massive ascites without evidence of malignant disease as confirmed by cytology. She was diagnosed with SS based on dysfunction of salivary secretion and positivity for anti-Ro/SS-A and La/SS-B antibodies, accompanied by clinical features of TAFRO syndrome based on the presence of anasarca and thrombocytopenia. High-dose corticosteroid for inflammation, anasarca, and thrombocytopenia was not effective. Cyclosporine was administered next, but anasarca and thrombocytopenia did not immediately improve until tolvaptan and eltrombopag were added. Although tolvaptan and eltrombopag were used for only a few months, the patient maintained a good condition with cyclosporine and low-dose prednisolone. In SS patients, activation of antigen-specific T lymphocytes is thought to be an important trigger that accelerates the immune response and is followed by hypercytokinemia. Therefore, using cyclosporine to suppress the activity of T lymphocytes is a reasonable treatment for SS accompanied with TAFRO syndrome-like pathophysiology. It might also be useful to administer tolvaptan or eltrombopag before the effects of immunosuppressants appear. If refractory inflammation with anasarca, thrombocytopenia, or lymphadenopathy is observed in an SS patient, complications with TAFRO syndrome-like pathophysiology should be considered.
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Nishimura Y, Hanayama Y, Fujii N, Kondo E, Otsuka F. Comparison of the clinical characteristics of TAFRO syndrome and idiopathic multicentric Castleman disease in general internal medicine: a 6‐year retrospective study. Intern Med J 2020; 50:184-191. [DOI: 10.1111/imj.14404] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 05/03/2019] [Accepted: 06/09/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Yoshito Nishimura
- Department of General MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Yoshihisa Hanayama
- Department of General MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Nobuharu Fujii
- Department of General MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
- Department of Hematology, Oncology, Allergy and Respiratory MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Eisei Kondo
- Department of HematologyKawasaki Medical School Okayama Japan
| | - Fumio Otsuka
- Department of General MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
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Hibi A, Mizuguchi K, Yoneyama A, Kasugai T, Kamiya K, Kamiya K, Ito C, Kominato S, Miura T, Koyama K. Severe refractory TAFRO syndrome requiring continuous renal replacement therapy complicated with Trichosporon asahii infection in the lungs and myocardial infarction: an autopsy case report and literature review. RENAL REPLACEMENT THERAPY 2018; 4:16. [PMID: 34171004 PMCID: PMC7149248 DOI: 10.1186/s41100-018-0157-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/22/2018] [Indexed: 01/09/2023] Open
Abstract
Background TAFRO (thrombocytopenia, anasarca, fever, reticulin myelofibrosis/renal failure, and organomegaly) syndrome is a systemic inflammatory disorder and unique clinicopathological variant of idiopathic multicentric Castleman disease that was proposed in Japan. Prompt diagnosis is critical because TAFRO syndrome is a progressive and life threating disease. Some cases are refractory to immunosuppressive treatments. Renal impairment is frequently observed in patients with TAFRO syndrome, and some severe cases require hemodialysis. Histological evaluation is important to understand the pathophysiology of TAFRO syndrome. However, systemic histopathological evaluation through autopsy in TAFRO syndrome has been rarely reported previously. Case presentation A 46-year-old Japanese man with chief complaints of fever and abdominal distension was diagnosed with TAFRO syndrome through imaging studies, laboratory findings, and pathological findings on cervical lymph node and bone marrow biopsies. Interleukin (IL)-6 and vascular endothelial growth factor (VEGF) levels were remarkably elevated in both blood and ascites. Methylprednisolone (mPSL) pulse therapy was initiated on day 10, followed by combination therapy with PSL and cyclosporine A. However, the amount of ascites did not respond to the treatment. The patient became anuric, and continuous renal replacement therapy was initiated from day 50. However, the patient suddenly experienced cardiac arrest associated with myocardial infarction (MI) on the same day. Although the emergent percutaneous coronary intervention was successfully performed, the patient died on day 52, despite intensive care. Autopsy was performed to ascertain the cause of MI and to identify the histopathological characteristics of TAFRO syndrome. Conclusions Bacterial peritonitis, systemic cytomegalovirus infection, and Trichosporon asahii infection in the lungs were observed on autopsy. In addition, sepsis-related myocardial calcification was suspected. Management of infectious diseases is critical to reduce mortality in patients with TAFRO syndrome. Although the exact cause of MI could not be identified on autopsy, we considered embolization by fungal hyphae as a possible cause. Endothelial injury possibly caused by excessive secretion of IL-6 and VEGF contributed to renal impairment. Fibrotic changes in anterior mediastinal fat tissue could be a characteristic pathological finding in patients with TAFRO syndrome.
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Affiliation(s)
- Arata Hibi
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, 5-15, Sumiyoshi-cho, Kariya, Aichi 448-8505 Japan
| | - Ken Mizuguchi
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, 5-15, Sumiyoshi-cho, Kariya, Aichi 448-8505 Japan
| | - Akiko Yoneyama
- Deaprtment of Pathology, Kariya Toyota General Hospital, 5-15, Sumiyoshi-cho, Kariya, Aichi 448-8505 Japan
| | - Takahisa Kasugai
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, 5-15, Sumiyoshi-cho, Kariya, Aichi 448-8505 Japan
| | - Keisuke Kamiya
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, 5-15, Sumiyoshi-cho, Kariya, Aichi 448-8505 Japan
| | - Keisuke Kamiya
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Chiharu Ito
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, 5-15, Sumiyoshi-cho, Kariya, Aichi 448-8505 Japan
| | - Satoru Kominato
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, 5-15, Sumiyoshi-cho, Kariya, Aichi 448-8505 Japan
| | - Toshiyuki Miura
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, 5-15, Sumiyoshi-cho, Kariya, Aichi 448-8505 Japan
| | - Katsushi Koyama
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Kariya Toyota General Hospital, 5-15, Sumiyoshi-cho, Kariya, Aichi 448-8505 Japan
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Fujimoto S, Kawabata H, Kurose N, Kawanami-Iwao H, Sakai T, Kawanami T, Fujita Y, Fukushima T, Masaki Y. Sjögren's syndrome manifesting as clinicopathological features of TAFRO syndrome: A case report. Medicine (Baltimore) 2017; 96:e9220. [PMID: 29390349 PMCID: PMC5815761 DOI: 10.1097/md.0000000000009220] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
RATIONALE TAFRO syndrome is a newly proposed disorder that manifests as thrombocytopenia, anasarca, fever, reticulin myelofibrosis, renal dysfunction, and organomegaly. In this report, we describe the development of severe TAFRO syndrome-like systemic symptoms during the clinical course of juvenile-onset Sjögren's syndrome in a 32-year-old woman. PATIENT CONCERNS The patient was admitted due to dyspnea, fever, polyarthralgia, and generalized edema. She had been diagnosed with Sjögren's syndrome at the age of 14 years, based on histopathological examination of a biopsy of the minor salivary glands and the development of Raynaud's phenomenon, with no follow-up treatment required. On admission, she presented with anemia, elevated C-reactive protein levels, anasarca, and hepato-splenomegaly. A bone marrow examination revealed increased megakaryocytes with reticulin fibrosis, and the histopathology of an axillary lymph node was consistent with mixed-type Castleman disease. Eventually, she developed thrombocytopenia. INTERVENTIONS Her symptoms fulfilled all of the major and minor categories of the diagnostic criteria for TAFRO syndrome. However, considering her prior diagnosis, we assumed that the clinical presentation was consistent with an acute exacerbation of Sjögren's syndrome. Unlike typical cases of TAFRO syndrome, the administration of relatively low-dose prednisolone relieved her symptoms. LESSONS Differentiation between TAFRO syndrome and exacerbation of an autoimmune disease is clinically important, although this can be challenging. Identification of specific biomarkers for TAFRO syndrome would be clinically beneficial.
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Affiliation(s)
- Shino Fujimoto
- Department of Hematology and Immunology, Kanazawa Medical University
| | - Hiroshi Kawabata
- Department of Hematology and Immunology, Kanazawa Medical University
| | - Nozomu Kurose
- Department of Pathology and Laboratory Medicine, Kanazawa Medical University, Daigaku, Uchinada, Ishikawa-ken, Japan
| | | | - Tomoyuki Sakai
- Department of Hematology and Immunology, Kanazawa Medical University
| | - Takafumi Kawanami
- Department of Hematology and Immunology, Kanazawa Medical University
| | - Yoshimasa Fujita
- Department of Hematology and Immunology, Kanazawa Medical University
| | | | - Yasufumi Masaki
- Department of Hematology and Immunology, Kanazawa Medical University
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Louis C, Vijgen S, Samii K, Chalandon Y, Terriou L, Launay D, Fajgenbaum DC, Seebach JD, Muller YD. TAFRO Syndrome in Caucasians: A Case Report and Review of the Literature. Front Med (Lausanne) 2017; 4:149. [PMID: 29018798 PMCID: PMC5614916 DOI: 10.3389/fmed.2017.00149] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 08/31/2017] [Indexed: 12/30/2022] Open
Abstract
Background TAFRO syndrome has been reported in Japan among human herpesvirus 8 (HHV-8)-negative/idiopathic multicentric Castleman’s disease (iMCD) patients. To date, the majority of iMCD patients with TAFRO syndrome originate from Japan. Case presentation Herein, we report a 67-year-old HIV/HHV-8-negative Caucasian iMCD patient diagnosed with TAFRO. He presented with marked systemic inflammation, bicytopenia, terminal renal insufficiency, diffuse lymphadenopathies, and anasarca. Lymph node and bone marrow biopsies revealed atrophic germinal centers variably hyalinized and megakaryocytic hyperplasia with mild myelofibrosis. Several other biopsies performed in kidneys, liver, gastrointestinal tract, prostate, and lungs revealed unspecific chronic inflammation. The patient had a complete response to corticosteroids, tocilizumab, and rituximab. He relapsed twice following discontinuation of rituximab. When reviewing the literature, we found seven other Caucasian cases with TAFRO syndrome. There were no significant differences with those described by the Japanese cohort except for the higher frequency of kidney failure and auto-antibodies in Western patients. Conclusion This case illustrates that patients with TAFRO syndrome can develop non-specific inflammation in several tissue sites. Furthermore, this case and our review of the literature demonstrate that TAFRO syndrome can affect Caucasian and Japanese patients highlighting the importance of evaluating for this syndrome independently of ethnic background.
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Affiliation(s)
- Céline Louis
- Division of Hematology, Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Sandrine Vijgen
- Department of Pathology, Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Kaveh Samii
- Division of Hematology, Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Yves Chalandon
- Division of Hematology, Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Louis Terriou
- Department of Internal Medicine and Clinical Immunology CHU, University of Lille, U995, Lille Inflammation Research International Center, INSERM, Centre national de référence maladies systémiques et auto-immunes rares (sclérodermie systémique), Lille, France
| | - David Launay
- Department of Internal Medicine and Clinical Immunology CHU, University of Lille, U995, Lille Inflammation Research International Center, INSERM, Centre national de référence maladies systémiques et auto-immunes rares (sclérodermie systémique), Lille, France
| | - David C Fajgenbaum
- Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Jörg D Seebach
- Division of Clinical Immunology and Allergy, Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Yannick D Muller
- Division of Clinical Immunology and Allergy, Geneva University Hospital, University of Geneva, Geneva, Switzerland
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