背景:巨噬细胞活化综合征(MAS)是风湿性疾病的严重并发症。我们描述了一个快速进展的病人,难治性MAS发现具有抗MDA5抗体幼年皮肌炎(JDM)作为她的风湿病诊断。
方法:我们描述了一名14岁的女性,她在入院时有6周的每日发烧史,并且无意中体重减轻了16磅。系统审查对咳嗽很重要,呼吸急促,胸痛,头痛,喉咙痛,肌肉疼痛,皮疹,恶心,和食欲不振。广泛的初步检查揭示了与自身免疫过程一致的发现。在等待检查结果的同时,她患有多器官系统受累的临床代偿失调,包括全血细胞减少症,间质性肺病,肝炎,心脏受累,胃肠扩张和疼痛,喂养不耐受,广泛的粘膜皮肤念珠菌病,和神经精神衰退。由于她的代偿失调,显著的间质性肺病,并且可能是潜在的风湿病,她开始服用高剂量脉冲类固醇和霉酚酸酯。由于她的转胺炎和肩痛,显示出明显的肌炎,因此进行了MRI检查。然后开始静脉免疫球蛋白。在她的检查早期发送的肌炎抗体小组对于抗MDA5和抗SSA-52抗体具有重要意义。尽管脉冲类固醇剂量高,霉酚酸酯,还有IVIG,她的疾病进展需要逐步升级的治疗。最终,她以MAS的决心以及喂养不耐受的显着和稳定的改善做出了回应,间质性肺病,心功能不全,肌炎,关节炎,和皮肤发现。
结论:JDM在儿科患者中是罕见的,就像MAS一样。在患有复杂风湿病且对治疗缺乏反应的患者中,在考虑MAS的情况下不断评估患者的临床状态是很重要的,因为这可能会改变治疗方法。没有正确认识到这种复杂性,患者的诊断可能会出现明显的延迟,从而导致危及生命的后果.
BACKGROUND: Macrophage activation syndrome (MAS) is a severe and under-recognized complication of rheumatologic diseases. We describe a patient who presented with rapidly progressive, refractory MAS found to have anti-MDA5 antibody Juvenile Dermatomyositis (JDM) as her underlying rheumatologic diagnosis.
METHODS: We describe a 14-year-old female who at the time of admission had a history of daily fevers for 6 weeks and an unintentional sixteen-pound weight loss.
Review of systems was significant for cough, shortness of breath, chest pain, headaches, sore throat, muscle aches, rash, nausea, and loss of appetite. An extensive initial workup revealed findings consistent with an autoimmune process. While awaiting results of her workup she had clinical decompensation with multi-organ system involvement including pancytopenias, interstitial lung disease, hepatitis, cardiac involvement, gastrointestinal distension and pain, feeding intolerance, extensive mucocutaneous candidiasis, and neuropsychiatric decline. Due to her decompensation, significant interstitial lung disease, and likely underlying rheumatologic condition she was started on high dose pulse steroids and mycophenolate. An MRI was performed due to her transaminitis and shoulder pain revealing significant myositis. Intravenous immunoglobulin was then initiated. The myositis antibody panel sent early in her workup was significant for anti-MDA5 and anti-SSA-52 antibodies. Despite high dose pulse steroids, mycophenolate, and IVIG, her disease progressed requiring escalating therapies. Ultimately, she responded with resolution of her MAS as well as significant and steady improvement in her feeding intolerance, interstitial lung disease, cardiac dysfunction, myositis, arthritis, and cutaneous findings.
CONCLUSIONS: JDM in the pediatric patient is rare, as is MAS. In patients with complex rheumatologic conditions and lack of response to treatment, it is important to continually assess the patient\'s clinical status with MAS in mind, as this may change the treatment approach. Without proper recognition of this complication, patients can have a significant delay in diagnosis leading to life-threatening consequences.