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Hoi A, Igel T, Mok CC, Arnaud L. Systemic lupus erythematosus. Lancet 2024:S0140-6736(24)00398-2. [PMID: 38642569 DOI: 10.1016/s0140-6736(24)00398-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/28/2023] [Accepted: 02/25/2024] [Indexed: 04/22/2024]
Abstract
Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease characterised by the presence of autoantibodies towards nuclear antigens, immune complex deposition, and chronic inflammation at classic target organs such as skin, joints, and kidneys. Despite substantial advances in the diagnosis and management of SLE, the burden of disease remains high. It is important to appreciate the typical presentations and the diagnostic process to facilitate early referral and diagnosis for patients. In most patients, constitutional, mucocutaneous, and musculoskeletal symptoms represent the earliest complaints; these symptoms can include fatigue, lupus-specific rash, mouth ulcers, alopecia, joint pain, and myalgia. In this Seminar we will discuss a diagnostic approach to symptoms in light of the latest classification criteria, which include a systematic evaluation of clinical manifestations (weighted within each domain) and autoantibody profiles (such as anti-double-stranded DNA, anti-Sm, hypocomplementaemia, or antiphospholipid antibodies). Non-pharmacotherapy management is tailored to the individual, with specific lifestyle interventions and patient education to improve quality of life and medication (such as hydroxychloroquine or immunosuppressant) adherence. In the last decade, there have been a few major breakthroughs in approved treatments for SLE and lupus nephritis, such as belimumab, anifrolumab, and voclosporin. However the disease course remains variable and mortality unacceptably high. Access to these expensive medications has also been restricted across different regions of the world. Nonetheless, understanding of treatment goals and strategies has improved. We recognise that the main goal of treatment is the achievement of remission or low disease activity. Comorbidities due to both disease activity and treatment adverse effects, especially infections, osteoporosis, and cardiovascular disease, necessitate vigilant prevention and management strategies. Tailoring treatment options to achieve remission, while balancing treatment-related comorbidities, are priority areas of SLE management.
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Affiliation(s)
- Alberta Hoi
- Department of Rheumatology, Monash Health, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.
| | - Talia Igel
- Department of Rheumatology, Monash Health, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong Special Administrative Region, China
| | - Laurent Arnaud
- Department of Rheumatology, National Reference Center for Autoimmune Diseases, INSERM UMR-S 1109, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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2
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Bodra D, D'Souza AVL, Khan E. Acute Motor Axonal Neuropathy in Lupus Nephritis. Cureus 2024; 16:e55603. [PMID: 38586696 PMCID: PMC10998645 DOI: 10.7759/cureus.55603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/05/2024] [Indexed: 04/09/2024] Open
Abstract
A prevalent clinical scenario is provided in this case study, in which a 22-year-old lady with a five-year history of lupus nephritis with acute motor axonal neuropathy presents for therapy. The patient received immunomodulator medication and steroids to control her symptoms to keep up with her everyday life despite the absence of comorbidities such as hypertension, diabetes, and hypothyroidism. No laboratory measures were changed, including hemoglobin, serum creatinine, or thyroid function. Examining the nervous system indicated a potentially harmful consequence, underscoring the significance of prompt investigation and treatment. This research highlighted the importance of attention in cases with lupus nephritis, showing how early medical care can prevent serious neurological problems and contribute to the patient's general well-being.
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Affiliation(s)
- Diljeet Bodra
- Nephrology, Father Muller Medical College and Hospital, Mangalore, IND
| | | | - Essar Khan
- Nephrology, Father Muller Medical College and Hospital, Mangalore, IND
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3
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Rao M, Mikdashi J. A Framework to Overcome Challenges in the Management of Infections in Patients with Systemic Lupus Erythematosus. Open Access Rheumatol 2023; 15:125-137. [PMID: 37534019 PMCID: PMC10391536 DOI: 10.2147/oarrr.s295036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/18/2023] [Indexed: 08/04/2023] Open
Abstract
Infections remain one of the leading causes of death in systemic lupus erythematosus (SLE), despite awareness of factors contributing to increased susceptibility to infectious diseases in SLE. Clinicians report challenges and barriers when encountering infection in SLE as certain infections may mimic a lupus flare. There are no evidence-based practice guidelines in the management of fever in SLE, with suboptimal implementations of evidence-based benefits related to infectious disease control and/or prevention strategies in SLE. Vigilance in identifying an opportunistic infection must be stressed when confronted by a diagnostic challenge during a presentation with a febrile illness in SLE. A balanced approach must focus on management of infections in SLE, and reduction in the glucocorticoids dose, given the need to control lupus disease activity to avoid lupus related organ damage and mortality. Clinical judgement and application of biomarkers of lupus flares could reduce false positives and overdiagnosis and improve differentiation of infections from lupus flares. Further precision-based risk and screening measures must identify individuals who would benefit most from low dose immunosuppressive therapy, targeted immune therapy, and vaccination programs.
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Affiliation(s)
- Madhavi Rao
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jamal Mikdashi
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Maryland School of Medicine, Baltimore, MD, USA
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Qasim A, Itare V, Anwar MY, Arguello Perez E. A Rare Case of Kikuchi-Fujimoto Disease. Cureus 2023; 15:e39098. [PMID: 37332401 PMCID: PMC10270646 DOI: 10.7759/cureus.39098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
Kikuchi-Fujimoto disease (KFD) is an autoimmune condition that is more common in females and occurs in the third decade of life. The condition is usually benign and self-resolving and is characterized by fever, cervical lymphadenopathy, night sweats, myalgia, and rashes. The disease can be misdiagnosed as reactive follicular hyperplasia, tuberculous lymphadenitis, systemic lupus erythematosus, and malignant lymphoma. The diagnosis of KFD involves the excision of the affected lymph node. Although there is no specific treatment for the disease, usually symptomatic and supportive measures are effective; however, steroids and immunosuppressive therapies are considered in more severe cases. The disease lasts for around one to four months. The neurological complications include cerebellar ataxia, meningoencephalitis, and aseptic meningitis. Here, we describe the case of a 36-year-old male who presented with complaints of fever, malaise chills, anorexia, and fatigue associated with a tender right axillary lymph node. The patient underwent a biopsy which confirmed KFD and responded well to supportive therapy.
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Affiliation(s)
- Abeer Qasim
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Vikram Itare
- Internal Medicine, BronxCare Health System, Bronx, USA
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5
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Gheorghiu AM, Vrancianu C, Conea I, Boca A, Bolboceanu M, Draganescu C, Bojinca M, Ancuta I. Performance of the New 2019 European Alliance of Associations for Rheumatology/American College of Rheumatology Systemic Lupus Erythematosus Classification Criteria in a Large Unicentric Cohort. Diagnostics (Basel) 2022; 12:diagnostics12112778. [PMID: 36428838 PMCID: PMC9689809 DOI: 10.3390/diagnostics12112778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/13/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The recently published 2019 American College of Rheumatology/European Alliance of Associations for Rheumatology (ACR/EULAR) classification criteria for systemic lupus erythematosus (SLE) were developed to increase the reliability and identification of SLE, especially in early disease. With the emergence of several new drugs for SLE, identifying and treating patients early are more important than ever. Methods: Data of 446 SLE patients evaluated in our center between 1996−2019 and 226 controls with other autoimmune diseases evaluated between 2001−2022 were retrospectively analyzed. The sensitivity and specificity of the 2019 ACR/EULAR criteria were compared to the 2012 SLICC and the 1997 ACR criteria. Results: The 2019 ACR/EULAR criteria showed very good sensitivity (86.6%) compared to the 1997 ACR criteria (76.7%), p < 0.001, with a trend toward significance compared to the 2012 SLICC criteria (83.6%), p = 0.072. Their sensitivity remained high (87.6%) in patients with a short disease duration. The specificity of the 2019 ACR/EULAR criteria (91.2%) was statistically lower than the 2012 SLICC (96.0%) and 1997 ACR criteria (95.1%), p = 0.007 and p = 0.012, respectively, but still had a very high value. A total of 22 controls (9.7%) fulfilled at least one set of criteria (15 patients with MCTD, 5 with UCTD, and 2 with SSc). Conclusion: In this large real-life cohort, the 2019 ACR/EULAR criteria had very good performance compared to the 2012 SLICC and 1997 ACR criteria.
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Affiliation(s)
- Ana Maria Gheorghiu
- Internal Medicine and Rheumatology Department, Cantacuzino Clinical Hospital, 020475 Bucharest, Romania
- Department 5, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Correspondence:
| | - Cristina Vrancianu
- Internal Medicine and Rheumatology Department, Cantacuzino Clinical Hospital, 020475 Bucharest, Romania
- Department 5, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Iuliana Conea
- Internal Medicine and Rheumatology Department, Cantacuzino Clinical Hospital, 020475 Bucharest, Romania
- Department 5, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Aida Boca
- Internal Medicine and Rheumatology Department, Cantacuzino Clinical Hospital, 020475 Bucharest, Romania
- Department 5, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Madalina Bolboceanu
- Internal Medicine and Rheumatology Department, Cantacuzino Clinical Hospital, 020475 Bucharest, Romania
- Department 5, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | | | - Mihai Bojinca
- Internal Medicine and Rheumatology Department, Cantacuzino Clinical Hospital, 020475 Bucharest, Romania
- Department 5, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Ioan Ancuta
- Internal Medicine and Rheumatology Department, Cantacuzino Clinical Hospital, 020475 Bucharest, Romania
- Department 5, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
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González García A, Fernández-Martín J, Robles Marhuenda Á. Idiopathic multicentric Castleman disease and associated autoimmune and autoinflammatory conditions: practical guidance for diagnosis. Rheumatology (Oxford) 2022; 62:1426-1435. [PMID: 35997567 PMCID: PMC10070070 DOI: 10.1093/rheumatology/keac481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
Idiopathic multicentric Castleman disease (iMCD) is an infrequent and life-threatening disorder characterised by systemic inflammatory symptoms, generalised lymphadenopathy, polyclonal lymphocyte proliferation, and organ dysfunction caused by a hyperinflammatory state. It accounts for one third to one half of all multicentric Castleman disease (MCD) cases. iMCD is often associated with autoimmune manifestations that may precede the iMCD diagnosis, be identified at the same time or follow it. In addition, iMCD may also coincide with a number of autoimmune diseases (such as psoriasis or myasthenia gravis) or autoinflammatory diseases (such as familial Mediterranean fever). Moreover, diverse inflammatory disorders, such as rheumatoid arthritis, systemic lupus erythematosus, adult-onset Still disease, systemic juvenile idiopathic arthritis, immunoglobulin (IgG4) related disease, or the recently described VEXAS syndrome, can present clinical features or lymphadenopathy with histopathological "Castleman-like" findings compatible with those of iMCD. Given the iMCD clinical heterogeneity and the overlap with other autoimmune or autoinflammatory disorders, iMCD diagnosis can be challenging. In this review, we explore the overlap between iMCD and inflammatory diseases and provide practical guidance on iMCD diagnosis in order to avoid misdiagnosis and confusion with other autoimmune or autoinflammatory conditions.
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Affiliation(s)
- Andrés González García
- Systemic Autoimmune and Orphan Diseases Unit, Department of Internal Medicine, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Julián Fernández-Martín
- Internal Medicine Department, Hospital Álvaro Cunqueiro, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Ángel Robles Marhuenda
- Autoimmune Diseases Unit of the Internal Medicine Service, Hospital La Paz, Madrid, Spain
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Lee WF, Fan WL, Tseng MH, Yang HY, Huang JL, Wu CY. Characteristics and genetic analysis of patients suspected with early-onset systemic lupus erythematosus. Pediatr Rheumatol Online J 2022; 20:68. [PMID: 35964089 PMCID: PMC9375402 DOI: 10.1186/s12969-022-00722-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/24/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is rarely diagnosed before 5-years-old. Those with disease onset at a very young age are predicted by a higher genetic risk and a more severe phenotype. We performed whole-exome sequencing to survey the genetic etiologies and clinical manifestations in patients fulfilling 2012 SLICC SLE classification criteria before the age of 5. CASE PRESENTATION Among the 184 childhood-onset SLE patients regularly followed in a tertiary medical center in Taiwan, 7 cases (3.8%) of which onset ≦ 5 years of age were identified for characteristic review and genetic analysis. Compared to those onset at elder age, cases onset before the age of 5 are more likely to suffer from proliferative glomerulonephritis, renal thrombotic microangiopathy, neuropsychiatric disorder and failure to thrive. Causative genetic etiologies were identified in 3. In addition to the abundance of autoantibodies, patient with homozygous TREX1 (c.292_293 ins A) mutation presented with chilblain-like skin lesions, peripheral spasticity, endocrinopathy and experienced multiple invasive infections. Patient with SLC7A7 (c.625 + 1 G > A) mutation suffered from profound glomerulonephritis with full-house glomerular deposits as well as hyperammonemia, metabolic acidosis and episodic conscious disturbance. Two other cases harbored variants in lupus associating genes C1s, C2, DNASE1 and DNASE1L3 and another with CFHR4. Despite fulfilling the classification criteria for lupus, many of the patients required treatments beyond conventional therapy. CONCLUSIONS Genetic etiologies and lupus mimickers were found among a substantial proportion of patients suspected with early-onset SLE. Detail clinical evaluation and genetic testing are important for tailored care and personalized treatment.
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Affiliation(s)
- Wan-Fang Lee
- grid.413801.f0000 0001 0711 0593Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, No.5 Fu-Hsing St. Kuei Shan Hsiang, Taoyuan, Taoyuan Hsien Taiwan
| | - Wen-Lang Fan
- grid.413801.f0000 0001 0711 0593Genomic Medicine Research Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan ,grid.413804.aDepartment of Medical Research, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Min-Hua Tseng
- grid.145695.a0000 0004 1798 0922College of Medicine, Chang Gung University, Taoyuan, Taiwan ,grid.413801.f0000 0001 0711 0593Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Huang-Yu Yang
- grid.145695.a0000 0004 1798 0922College of Medicine, Chang Gung University, Taoyuan, Taiwan ,grid.413801.f0000 0001 0711 0593Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jing-Long Huang
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, No.5 Fu-Hsing St. Kuei Shan Hsiang, Taoyuan, Taoyuan Hsien, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Department of Pediatrics, New Taipei Municipal TuCheng Hospital, New Taipei city, Taiwan.
| | - Chao-Yi Wu
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, No.5 Fu-Hsing St. Kuei Shan Hsiang, Taoyuan, Taoyuan Hsien, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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8
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Schlencker A, Messer L, Ardizzone M, Blaison G, Hinschberger O, Dahan E, Sordet C, Walther J, Dory A, Gonzalez M, Kleinlogel S, Bramont-Nachman A, Barrand L, Payen-Revol I, Sibilia J, Martin T, Arnaud L. Improving patient pathways for systemic lupus erythematosus: a multistakeholder pathway optimisation study. Lupus Sci Med 2022; 9:9/1/e000700. [PMID: 35568439 PMCID: PMC9109107 DOI: 10.1136/lupus-2022-000700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/28/2022] [Indexed: 11/29/2022]
Abstract
Objective Among the most significant challenges in SLE are the excessive diagnosis delay and the lack of coordinated care. The aim of the study was to investigate patient pathways in SLE in order to improve clinical and organisational challenges in the management of those with suspected and confirmed SLE. Methods We conducted a cross-sectional study of patients with SLE, healthcare providers and other representative stakeholders. Focus groups were conducted, and based on the collected data the most impactful disruption points in SLE patient pathways were identified. A novel framework to improve individual patient pathways in SLE was developed, discussed and validated during a consensus meeting with representative stakeholders. Results Six thematic clusters regarding disruption in optimal patient pathways in SLE were identified: appropriate and timely referral strategy for SLE diagnosis; the need for a dedicated consultation during which the diagnosis of SLE would be announced, and following which clarifications and psychological support offered; individualised patient pathways with coordinated care based on organ involvement, disease severity and patient preference; improved therapeutic patient education; prevention of complications such as infections, osteoporosis and cancer; and additional patient support. During the consensus meeting, the broader panel of stakeholders achieved consensus on these attributes and a framework for optimising SLE patient pathways was developed. Conclusions We have identified significant disruption points and developed a novel conceptual framework to improve individual patient pathways in SLE. These data may be of valuable interest to patients with SLE, their physicians, health organisations as well as policy makers.
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Affiliation(s)
- Aurelien Schlencker
- Service de Rhumatologie, Hôpitaux universitaires de Strasbourg, Strasbourg, France.,Centre National de Références des Maladies Auto-immunes Rares (CRMR RESO), Strasbourg, France
| | - Laurent Messer
- Service de Rhumatologie, Hôpitaux Civils de Colmar, Colmar, France
| | - Marc Ardizzone
- Service de Rhumatologie, GHR Mulhouse Sud-Alsace, Mulhouse, France
| | - Gilles Blaison
- Service de médecine interne, Centre de compétence Maladies auto-immunes rares, Hôpitaux Civils de Colmar, Colmar, France
| | - Olivier Hinschberger
- Service de médecine interne, Centre de compétence Maladies auto-immunes rares, Hôpitaux Civils de Colmar, Colmar, France
| | - Etienne Dahan
- Service de Rhumatologie, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Christelle Sordet
- Service de Rhumatologie, Hôpitaux universitaires de Strasbourg, Strasbourg, France.,Centre National de Références des Maladies Auto-immunes Rares (CRMR RESO), Strasbourg, France
| | - Julia Walther
- Service de pharmacie stérilisation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Anne Dory
- Service de pharmacie stérilisation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Maria Gonzalez
- Service de Pathologie Professionnelle et de Médecine du Travail, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Stéphanie Kleinlogel
- Service de Pathologie Professionnelle et de Médecine du Travail, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Aurélia Bramont-Nachman
- Service de Pathologie Professionnelle et de Médecine du Travail, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | | | - Jean Sibilia
- Service de Rhumatologie, Hôpitaux universitaires de Strasbourg, Strasbourg, France.,Centre National de Références des Maladies Auto-immunes Rares (CRMR RESO), Strasbourg, France
| | - Thierry Martin
- Centre National de Références des Maladies Auto-immunes Rares (CRMR RESO), Strasbourg, France.,Service d'immunologie clinique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Laurent Arnaud
- Service de Rhumatologie, Hôpitaux universitaires de Strasbourg, Strasbourg, France .,Centre National de Références des Maladies Auto-immunes Rares (CRMR RESO), Strasbourg, France
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Abstract
Autoimmune lymphoproliferative syndrome (ALPS) is a primary immune regulatory disorder characterized by benign or malignant lymphoproliferation and autoimmunity. Classically, ALPS is due to mutations in FAS and other related genes; however, recent research revealed that other genes could be responsible for similar clinical features. Therefore, ALPS classification and diagnostic criteria have changed over time, and several ALPS-like disorders have been recently identified. Moreover, mutations in FAS often show an incomplete penetrance, and certain genotypes have been associated to a dominant or recessive inheritance pattern. FAS mutations may also be acquired or could become pathogenic when associated to variants in other genes, delineating a possible digenic type of inheritance. Intriguingly, variants in FAS and increased TCR αβ double-negative T cells (DNTs, a hallmark of ALPS) have been identified in multifactorial autoimmune diseases, while FAS itself could play a potential role in carcinogenesis. These findings suggest that alterations of FAS-mediated apoptosis could trespass the universe of inborn errors of immunity and that somatic mutations leading to ALPS could only be the tip of the iceberg of acquired immunodeficiencies.
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Affiliation(s)
- Filippo Consonni
- Anna Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Eleonora Gambineri
- Division of Pediatric Oncology/Hematology, BMT Unit, Meyer University Children's Hospital, Viale Gaetano Pieraccini 24, 50139, Florence, Italy.
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy.
| | - Claudio Favre
- Division of Pediatric Oncology/Hematology, BMT Unit, Meyer University Children's Hospital, Viale Gaetano Pieraccini 24, 50139, Florence, Italy
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10
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Alrumayyan N, Slauenwhite D, McAlpine SM, Roberts S, Issekutz TB, Huber AM, Liu Z, Derfalvi B. Prolidase deficiency, a rare inborn error of immunity, clinical phenotypes, immunological features, and proposed treatments in twins. Allergy Asthma Clin Immunol 2022; 18:17. [PMID: 35197125 PMCID: PMC8867623 DOI: 10.1186/s13223-022-00658-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/09/2022] [Indexed: 12/30/2022]
Abstract
Background Prolidase deficiency (PD) is an autosomal recessive inborn multisystemic disease caused by mutations in the PEPD gene encoding the enzyme prolidase D, leading to defects in turnover of proline-containing proteins, such as collagen. PD is categorized as a metabolic disease, but also as an inborn error of immunity. PD presents with a range of findings including dysmorphic features, intellectual disabilities, recurrent infections, intractable skin ulceration, autoimmunity, and splenomegaly. Despite symptoms of immune dysregulation, only very limited immunologic assessments have been reported and standard therapies for PD have not been described. We report twin females with PD, including comprehensive immunologic profiles and treatment modalities used. Case presentation Patient 1 had recurrent infections in childhood. At age 13, she presented with telangiectasia, followed by painful, refractory skin ulcerations on her lower limbs, where skin biopsy excluded vasculitis. She had typical dysmorphic features of PD. Next-generation sequencing revealed pathogenic compound heterozygous mutations (premature stop codons) in the PEPD gene. Patient 2 had the same mutations, typical PD facial features, atopy, and telangiectasias, but no skin ulceration. Both patients had imidodipeptiduria. Lymphocyte subset analysis revealed low-normal frequency of Treg cells and decreased frequency of expression of the checkpoint molecule CTLA-4 in CD4+ TEM cells. Analysis of Th1, Th2, and Th17 profiles revealed increased inflammatory IL-17+ CD8+ TEM cells in both patients and overexpression of the activation marker HLA-DR on CD4+ TEM cells, reflecting a highly activated proinflammatory state. Neither PD patient had specific antibody deficiencies despite low CD4+CXCR5+ Tfh cells and low class-switched memory B cells. Plasma IL-18 levels were exceptionally high. Conclusions Immunologic abnormalities including skewed frequencies of activated inflammatory CD4+ and CD8+ TEM cells, decreased CTLA-4 expression, and defects in memory B cells may be a feature of immune dysregulation associated with PD; however, a larger sample size is required to validate these findings. The high IL-18 plasma levels suggest underlying autoinflammatory processes.
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Affiliation(s)
- Nora Alrumayyan
- Division of Immunology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Drew Slauenwhite
- Division of Immunology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Sarah M McAlpine
- Division of Immunology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Sarah Roberts
- Division of Immunology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Thomas B Issekutz
- Division of Immunology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Adam M Huber
- Division of Rheumatology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Zaiping Liu
- Division of Clinical Biochemistry & Maritime Newborn Screening, Department of Pathology and Laboratory Medicine, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Beata Derfalvi
- Division of Immunology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada.
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11
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Bao D, Tan Y, Yu X, Wang B, Wang H, Xu R, Zhou F, Zhao M. Case Report: A Rare Case of Lupus Nephritis Associated With Mantle Cell Lymphoma. Front Med (Lausanne) 2021; 8:759279. [PMID: 34912821 PMCID: PMC8666564 DOI: 10.3389/fmed.2021.759279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022] Open
Abstract
In this research, we described a very rare case of secondary lupus nephritis associated with B-cell lymphoma. An 84-year-old man was hospitalized at our institute for lower extremity edema persisting for over 2 months. He was diagnosed with systemic lupus erythematosus based on clinical and laboratory criteria, which showed impaired renal function and nephrotic syndrome with predominant hematuria. Renal biopsy showed IV+V lupus nephritis with highly infiltrated lymphoid cells in the kidney. Secondary lupus nephritis was suspected based on the possible pathogenesis of glomerular injury due to mantle cell lymphoma. Low-dose dexamethasone, rituximab, and lenalidomide were immediately started on the patient, and his renal function was improved after the first cycle of chemotherapy.
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Affiliation(s)
- Daorina Bao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Tan
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaojuan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Bingjie Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Hui Wang
- Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China
| | - Rong Xu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Fude Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
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12
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Kuroda K, Tambe A, Iftikhar R, Nat AS, Basnet A. A Case of Angioimmunoblastic T-cell Lymphoma That Mimics As Autoimmune Diseases and Infections. Cureus 2021; 13:e16439. [PMID: 34422471 PMCID: PMC8366574 DOI: 10.7759/cureus.16439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 11/05/2022] Open
Abstract
Angioimmunoblastic T-cell lymphoma (AITL) is an aggressive malignancy with a presentation like either autoimmune diseases, drug reactions, or infections. We hereby present a unique case of AITL. A 61-year-old Caucasian male with a past medical history of chronic obstructive pulmonary disease (COPD) presented to the emergency department with a rash over his bilateral knees, shortness of breath, and productive cough of few days. He was managed for suspected COPD exacerbation associated with community-acquired pneumonia. On the day of admission patient was having an itchy maculopapular rash, ecchymosis on the left flank, and generalized lymphadenopathy. Physical exam showed generalized lymphadenopathy. Laboratory tests revealed leukocytosis, thrombocytopenia and were positive for multiple autoantibodies. Epstein-Barr virus polymerase chain reaction and hepatitis B virus core antibody were positive. Skin biopsy revealed findings suggestive of a small vessel vasculitis. Inguinal lymph node biopsy showed AITL. The patient recovered with chemotherapy. The case illustrates that clinical presentation of AITL mimics rheumatologic disorders and infections. This complexity could arise from the follicular T helper cell, which is an important checkpoint for B cell activation and differentiation. Additionally, skin involvement is one of the important findings of AITL and a variety of lesions have been reported as skin manifestations.
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Affiliation(s)
- Kaku Kuroda
- Family Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Ajay Tambe
- Hematology and Oncology, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Rahila Iftikhar
- Family Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Amitpal S Nat
- Internal Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Alina Basnet
- Hematology and Oncology, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
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13
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Kadoba K, Nishimura K, Uchino K, Waki D, Murabe H, Yokota T. Age-related Epstein-Barr Virus-associated Lymphoproliferative Disorder Masquerading as Systemic Lupus Erythematosus. Intern Med 2021; 60:2495-2497. [PMID: 33583902 PMCID: PMC8381174 DOI: 10.2169/internalmedicine.6702-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Age-related Epstein-Barr virus (EBV)-positive B-cell lymphoproliferative disorder (LPD) occurs in elderly patients without immunodeficiency. An 81-year-old woman without any known immunodeficiency was examined for fever, rash, arthritis, thrombocytopenia, pleural and pericardial effusions, lymphadenopathy, and positive autoantibodies, which satisfied the classification criteria for systemic lupus erythematosus (SLE). However, a lymph node biopsy revealed EBV-LPD, and she was diagnosed with age-related EBV-LPD. In young individuals, EBV infection is a major differential diagnosis of SLE, but to our knowledge, this is the first reported case of age-related EBV-LPD mimicking SLE. We should therefore consider EBV-related disorders in the differential diagnosis of SLE even in elderly individuals.
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Affiliation(s)
- Keiichiro Kadoba
- Department of Endocrinology and Rheumatology, Kurashiki Central Hospital, Japan
| | - Keisuke Nishimura
- Department of Endocrinology and Rheumatology, Kurashiki Central Hospital, Japan
| | - Kaori Uchino
- Department of Anatomic Pathology, Kurashiki Central Hospital, Japan
| | - Daisuke Waki
- Department of Endocrinology and Rheumatology, Kurashiki Central Hospital, Japan
| | - Hiroyuki Murabe
- Department of Endocrinology and Rheumatology, Kurashiki Central Hospital, Japan
| | - Toshihiko Yokota
- Department of Endocrinology and Rheumatology, Kurashiki Central Hospital, Japan
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14
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Bağlan E, Özdel S, Güngör T, Karakuş R, Bağrıaçık EÜ, Yücel AA, Bülbül M. Spondylenchondrodysplasia mimicking a systemic lupus erythematosus: A diagnostic challenge in a pediatric patient. Eur J Med Genet 2021; 64:104286. [PMID: 34245909 DOI: 10.1016/j.ejmg.2021.104286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 05/03/2021] [Accepted: 05/20/2021] [Indexed: 11/19/2022]
Abstract
Spondyloenchondrodysplasia (SPENCD) is a rare autosomal recessive skeletal dysplasia caused by biallelic mutations in the ACP5 gene that encodes tartrate-resistant acid phosphatase (TRAP). The extra-osseous phenotype of SPENCD is extremely pleiotropic and is characterized by neurological impairment and immune dysfunction. This phenotype can mimic systemic lupus erythematosus. Herein, we report a child presented with systemic lupus erythematosus-like symptoms, including multisystem inflammation, autoimmunity, and immunodeficiency, but was subsequently diagnosed as SPENCD.
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Affiliation(s)
- Esra Bağlan
- Department of Pediatric Rheumatology and Nephrology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Semanur Özdel
- Department of Pediatric Rheumatology and Nephrology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Tülin Güngör
- Department of Pediatric Rheumatology and Nephrology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Resul Karakuş
- Gazi University Faculty of Medicine, Department of Immunology, Ankara, Turkey.
| | - Emin Ümit Bağrıaçık
- Gazi University Faculty of Medicine, Department of Immunology, Ankara, Turkey.
| | - Ayşegül Atak Yücel
- Gazi University Faculty of Medicine, Department of Immunology, Ankara, Turkey.
| | - Mehmet Bülbül
- Department of Pediatric Rheumatology and Nephrology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey.
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15
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Affiliation(s)
| | - Petra De Haes
- Department of Dermatology, University Hospitals Leuven, Leuven, Belgium
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16
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Magallares B, Lobo-Prat D, Castellví I, Moya P, Gich I, Martinez-Martinez L, Park H, Millán AM, Laiz A, Díaz-Torné C, Fernandez S, Corominas H. Assessment of EULAR/ACR-2019, SLICC-2012 and ACR-1997 Classification Criteria in SLE with Longstanding Disease. J Clin Med 2021; 10:jcm10112377. [PMID: 34071275 PMCID: PMC8198204 DOI: 10.3390/jcm10112377] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Different classification criteria for systemic lupus erythematosus (SLE) have been launched over the years. Our aim was to evaluate the performance of the EULAR/ACR-2019, SLICC-2012 and ACR-1997 classification criteria in a cohort of SLE patients with longstanding disease. METHODS Descriptive observational study in 79 patients with established and longstanding SLE. The three classification criteria sets were applied to those patients. RESULTS Of the 79 patients, 70 were women (88.6%), with a mean age of 51.8 ± 14 years and a mean disease duration of 15.2 ± 11.5 years. The sensitivity of the different criteria were: 51.9%, 87.3% and 86.1% for ACR-1997, SLICC-2012 and EULAR/ACR-2019, respectively. In total, 68 out of 79 patients (53.7%) met all three classification criteria; 11.4% did not meet any classification criteria and were characterized by low SLEDAI (0.6 ± 0.9), low SLICC/ACR Damage Index (0.88 ± 0.56) and fulfilling only skin domains, antiphospholipid antibodies or hypocomplementemia. To fulfill EULAR/ACR-2019 criteria was associated with low complement levels (p < 0.04), high anti-dsDNA levels (p < 0.001), presence of lupus nephritis III-IV (p < 0.05) and arthritis (p < 0.001). CONCLUSION The EULAR/ACR-2019 classification criteria showed high sensitivity, similar to SLICC-2012, in SLE patients with longstanding disease. Patients with serological, articular or renal involvement are more likely to fulfill SLICC-2012 or EULAR/ACR-2019 criteria.
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Affiliation(s)
- Berta Magallares
- Department of Rheumatology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (B.M.); (D.L.-P.); (I.C.); (P.M.); (H.P.); (A.M.M.); (A.L.); (C.D.-T.); (S.F.)
- Sant Pau Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain;
- Department of Immunology, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
| | - David Lobo-Prat
- Department of Rheumatology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (B.M.); (D.L.-P.); (I.C.); (P.M.); (H.P.); (A.M.M.); (A.L.); (C.D.-T.); (S.F.)
| | - Ivan Castellví
- Department of Rheumatology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (B.M.); (D.L.-P.); (I.C.); (P.M.); (H.P.); (A.M.M.); (A.L.); (C.D.-T.); (S.F.)
- Sant Pau Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain;
- Department of Immunology, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
| | - Patricia Moya
- Department of Rheumatology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (B.M.); (D.L.-P.); (I.C.); (P.M.); (H.P.); (A.M.M.); (A.L.); (C.D.-T.); (S.F.)
- Sant Pau Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain;
- Department of Immunology, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
| | - Ignasi Gich
- Sant Pau Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain;
- CIBER Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain
- Department of Clinical Epidemiology and Public Health, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain
| | | | - Hye Park
- Department of Rheumatology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (B.M.); (D.L.-P.); (I.C.); (P.M.); (H.P.); (A.M.M.); (A.L.); (C.D.-T.); (S.F.)
| | - Ana Milena Millán
- Department of Rheumatology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (B.M.); (D.L.-P.); (I.C.); (P.M.); (H.P.); (A.M.M.); (A.L.); (C.D.-T.); (S.F.)
| | - Ana Laiz
- Department of Rheumatology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (B.M.); (D.L.-P.); (I.C.); (P.M.); (H.P.); (A.M.M.); (A.L.); (C.D.-T.); (S.F.)
- Sant Pau Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain;
- Department of Immunology, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
| | - César Díaz-Torné
- Department of Rheumatology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (B.M.); (D.L.-P.); (I.C.); (P.M.); (H.P.); (A.M.M.); (A.L.); (C.D.-T.); (S.F.)
- Sant Pau Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain;
- Department of Immunology, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
| | - Susana Fernandez
- Department of Rheumatology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (B.M.); (D.L.-P.); (I.C.); (P.M.); (H.P.); (A.M.M.); (A.L.); (C.D.-T.); (S.F.)
| | - Hèctor Corominas
- Department of Rheumatology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (B.M.); (D.L.-P.); (I.C.); (P.M.); (H.P.); (A.M.M.); (A.L.); (C.D.-T.); (S.F.)
- Sant Pau Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain;
- Department of Immunology, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
- Correspondence: ; Tel.: +34-932919000
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17
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Demuth S, Felten R, Sordet C, Chatelus E, Chanson JB, Arnaud L. Rheumatic presentations of Guillain-Barré syndrome as a diagnostic challenge: A case series. Joint Bone Spine 2021; 88:105144. [PMID: 33515790 DOI: 10.1016/j.jbspin.2021.105144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Guillain-Barré syndrome (GBS) is an immune-mediated acute polyradiculoneuritis often in post-infectious context. It is a therapeutic emergency as early treatment may prevent disabilities. Pain in GBS has been described extensively, may precede neurological symptoms and bring the patient to rheumatology departments in the first place. OBJECTIVE To describe the clinical presentations and diagnosis of GBS cases referred to rheumatology departments. METHOD For this retrospective case-series, we screened patients of the rheumatology department (university hospitals of Strasbourg), whose hospitalization records were associated with the ICD-10 Code G61.0 (GBS) from 1993 to 2020. We included patients fulfilling the 1990 NINDS criteria and level one of the Brighton collaboration criteria. We measured the time from symptoms onset to admission and from admission to lumbar puncture as a marker of outpatient and inpatient diagnosis delay, respectively. RESULTS We describe 8 GBS cases. Six had nociceptive-like prodromal pain: back pain (n=3), peripheral arthralgia (n=1) or diffuse myalgia (n=3). The median time from symptoms onset to admission was 7days [range: 3-60] and the median time from admission to lumbar puncture was 2days [range: 0-8]. Two patients became severely tetraparetic, one requiring intubation. At last follow-up (median: 5.5years; range: 0.5-23years), 4 patients had recovered completely and 4 kept disabilities. CONCLUSIONS Rheumatic presentations of GBS are rare and diverse. Rheumatologists should be aware of this presentation because early diagnosis and treatment may prevent rapid motor worsening. Rapidly progressive symmetric weakness and areflexia appear as the best clinical diagnosis markers.
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Affiliation(s)
- Stanislas Demuth
- Service de rhumatologie, Centre National de Référence des Maladies Auto-Immunes (RESO), Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Renaud Felten
- Service de rhumatologie, Centre National de Référence des Maladies Auto-Immunes (RESO), Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Christelle Sordet
- Service de rhumatologie, Centre National de Référence des Maladies Auto-Immunes (RESO), Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Emmanuel Chatelus
- Service de rhumatologie, Centre National de Référence des Maladies Auto-Immunes (RESO), Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Jean-Baptiste Chanson
- Service de neurologie, Hôpitaux Universitaires de Strasbourg, 1, avenue Molière, 67000 Strasbourg, France
| | - Laurent Arnaud
- Service de rhumatologie, Centre National de Référence des Maladies Auto-Immunes (RESO), Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France.
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18
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Piga M, Arnaud L. The Main Challenges in Systemic Lupus Erythematosus: Where Do We Stand? J Clin Med 2021; 10:E243. [PMID: 33440874 PMCID: PMC7827672 DOI: 10.3390/jcm10020243] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/04/2021] [Accepted: 01/08/2021] [Indexed: 12/12/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an immune-mediated multi-systemic disease characterized by a wide variability of clinical manifestations and a course frequently subject to unpredictable flares. Despite significant advances in the understanding of the pathophysiology and optimization of medical care, patients with SLE still have significant mortality and carry a risk of progressive organ damage accrual and reduced health-related quality of life. New tools allow earlier classification of SLE, whereas tailored early intervention and treatment strategies targeted to clinical remission or low disease activity could offer the opportunity to reduce damage, thus improving long-term outcomes. Nevertheless, the early diagnosis of SLE is still an unmet need for many patients. Further disentangling the SLE susceptibility and complex pathogenesis will allow to identify more accurate biomarkers and implement new ways to measure disease activity. This could represent a major step forward to find new trials modalities for developing new drugs, optimizing the use of currently available therapeutics and minimizing glucocorticoids. Preventing and treating comorbidities in SLE, improving the management of hard-to-treat manifestations including management of SLE during pregnancy are among the remaining major unmet needs. This review provides insights and a research agenda for the main challenges in SLE.
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Affiliation(s)
- Matteo Piga
- Rheumatology Unit, AOU University Clinic and University of Cagliari, 09042 Cagliari, Italy;
| | - Laurent Arnaud
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France
- Centre National de Références des Maladies Systémiques et Auto-immunes Rares Est Sud-Ouest (RESO), 67000 Strasbourg, France
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Abstract
BACKGROUND Necrotizing lymphadenitis is a rare disease. It is often misdiagnosed because of the lack of typical clinical manifestations. It is worth noting that necrotizing lymphadenitis may be a precursor lesion of systemic lupus erythematosus or tumours, so regular follow-up is needed to facilitate early diagnosis. Here, we report a case and conduct a literature analysis summarizing the clinical features of necrotizing lymphadenitis and its treatment and management practices. CASE PRESENTATION A 16-year-old young woman presented with fever and lymphadenopathy as the main clinical manifestations, accompanied by a rash during fever that disappeared as the fever subsided. After completing imaging and laboratory examinations, we excluded other diseases such as infections, autoimmune diseases, and malignant tumours. Finally, we diagnosed the patient with necrotizing lymphadenitis based on the results of lymph node biopsy. The symptoms of the patient improved after glucocorticoid treatment, and she was followed up for half a year without recurrence of symptoms. CONCLUSION In the clinic, young women with fever and lymphadenopathy as major symptoms should be screened for necrotizing lymphadenitis to facilitate early diagnosis and treatment. Although necrotizing lymphadenitis is self-limiting, its clinical manifestations are similar to those of many diseases. Therefore, it is easily misdiagnosed. An in-depth understanding of the disease is conducive to early diagnosis and treatment in the clinic, thereby reducing further damage to the body and reducing unnecessary evaluation and treatment.
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Affiliation(s)
- J Huang
- Department of Rheumatology and Immunology, Daping Hospital, Army Medical University, No. 10, Changjiang Branch Road, Yuzhong District, 400042, Chongqing, China
| | - J-X Zheng
- Department of Rheumatology and Immunology, the Affiliated Hospital of North Sichuan Medical College, 637000, Nanchong, China
| | - Y Yang
- Department of Rheumatology and Immunology, Daping Hospital, Army Medical University, No. 10, Changjiang Branch Road, Yuzhong District, 400042, Chongqing, China.
| | - D Zhu
- Department of Rheumatology and Immunology, Daping Hospital, Army Medical University, No. 10, Changjiang Branch Road, Yuzhong District, 400042, Chongqing, China.
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Ahrari A, Barrett SS, Basharat P, Rohekar S, Pope JE. Appropriateness of laboratory tests in the diagnosis of inflammatory rheumatic diseases among patients newly referred to rheumatologists. Joint Bone Spine 2020; 87:588-95. [PMID: 32522598 DOI: 10.1016/j.jbspin.2020.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/14/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Autoantibody tests are commonly ordered when screening for rheumatic diseases. Rheumatoid factor (RF) and antinuclear antibody (ANA) have low positive predictive values in general practice. Overuse of diagnostic tests can result in an increase in unnecessary referrals, patient anxiety, and further costs. OBJECTIVE The objective was to evaluate the utilization patterns, appropriateness, and associated costs of tests including ANA, extractable nuclear antibodies (ENA), anti-double stranded DNA (anti-dsDNA), RF, and HLA-B27 in patients referred to rheumatologists. METHODS A review was conducted of consecutive referrals (accepted and rejected) using university rheumatologists' practices over one year. Inappropriate investigations, and associated costs were analyzed. Tests were considered appropriate if at least one criterion for a specific disease was provided. RESULTS Of 638 referrals the most common reported reasons for referral were: spondyloarthropathies (SpA), rheumatoid arthritis (RA), and lupus (SLE). Prior to referral: 61% had undergone ANA testing at least once, ANA was repeated in one third; 19% had ENA and 21% had anti-dsDNA. 20% had ANA testing with no clinical indication. Half of ENA and anti-dsDNA testing was in the context of a negative ANA. RF was requested in 65% and in close to one third, there was no clinical suspicion of inflammatory arthritis. CONCLUSION Despite the recommendations by CRA Choosing Wisely Campaign, at least 50% of laboratory investigations, including RF, ANA, ENA, and anti-dsDNA, are inappropriately ordered. More selective ordering of the above tests would lead to marked cost reduction.
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21
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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: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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