Letter to the Editor
Rhupus and Autoimmune Hepatitis: A Rare Association
Rupus y hepatitis autoinmune: una asociación infrecuente
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"https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574317301387?idApp=UINPBA00004M" "url" => "/21735743/0000001300000006/v1_201710250854/S2173574317301387/v1_201710250854/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "<span class="elsevierStyleItalic">Rhupus</span> and Autoimmune Hepatitis: A Rare Association" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "365" "paginaFinal" => "366" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ernesto Zavala-Flores, David Loja-Oropeza" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Ernesto" "apellidos" => "Zavala-Flores" "email" => array:1 [ 0 => "ernestozav123@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "David" "apellidos" => "Loja-Oropeza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Universidad San Martin de Porres, Lima, Peru" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Nacional Arzobispo Loayza, Lima, Peru" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Rupus y hepatitis autoinmune: una asociación infrecuente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 785 "Ancho" => 1047 "Tamanyo" => 339386 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Piecemeal necrosis with damage to the hepatocytes. Necroinflammatory lesion.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Overlap syndromes are uncommon conditions in which the diagnostic criteria of more than one systemic autoimmune disease are met in a single patient.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> In contrast to mixed connective tissue diseases (MCTD), in which certain clinical or serological characteristics are identified, they do not fulfill the diagnostic criteria in order to be categorized as a defined disease.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">“<span class="elsevierStyleItalic">Rhupus</span>” is an entity in which there is an overlap of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), and the incidence involves less than 1% of the SLE population.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a> Autoimmune hepatitis (AIH) is a chronic progressive liver disease. Its prevalence is relatively low, as it affects around 16.9 individuals in population of 100,000.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of a 30-year-old woman, with a history of RA, who came to the hospital with acute pyelonephritis. Therapy was begun with antibiotics and symptomatic treatment, and the patient responded favorably. Four days later, she presented with pain in hypogastrium and right hypochondriac region, nausea, vomiting, paleness, pain and stiffness in the metacarpophalangeal joint (with synovitis) and bilateral coxofemoral joint, red eye syndrome, malar erythema and photosensitivity.</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Ancillary tests</span>: albumin: 4<span class="elsevierStyleHsp" style=""></span>g/dL; globulin: 4<span class="elsevierStyleHsp" style=""></span>g/dL; immunoglobulin (Ig) G: 1669.4<span class="elsevierStyleHsp" style=""></span>mg/dL; IgM: 473.0<span class="elsevierStyleHsp" style=""></span>mg/dL; antinuclear antibodies positive: 1/400, homogeneous pattern; native SS-A<span class="elsevierStyleSup">+++</span>; single-stranded DNA<span class="elsevierStyleSup">++</span>; RNP: positive; RNP A: negative; RNP C: negative; Scl 70: negative; PM-Scl: negative; Jo-1: negative; centromere protein B: negative; serum complement C3-C4 level: low; lupus anticoagulant (kaolin): 0.83 (−); IgG anticardiolipin: 12 (+); IgM anticardiolipin: 19 (+); and beta 2 glycoprotein I: not determined.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Total bilirubin:</span> 1.5<span class="elsevierStyleHsp" style=""></span>mg/dL (0.4–1.2<span class="elsevierStyleHsp" style=""></span>mg/dL); direct bilirubin: 1<span class="elsevierStyleHsp" style=""></span>mg/dL (0–0.3<span class="elsevierStyleHsp" style=""></span>mg/dL; aspartate aminotransferase: 31<span class="elsevierStyleHsp" style=""></span>IU/L; alanine aminotransferase: 25<span class="elsevierStyleHsp" style=""></span>IU/L; gamma-glutamyltransferase: 61<span class="elsevierStyleHsp" style=""></span>IU/L; prothrombin time: 13.9<span class="elsevierStyleHsp" style=""></span>s; international normalized ratio (INR): 1.22; Australian antigen (HBsAg): negative; anti-hepatitis C virus: negative; anti-hepatitis A virus (HAV) IgM: negative; rheumatoid factor: 21<span class="elsevierStyleHsp" style=""></span>IU/mL; erythrocyte sedimentation rate: 66<span class="elsevierStyleHsp" style=""></span>mm/h; anti-smooth muscle antibodies (+); and anti-liver-kidney microsomal (LKM) antibody: negative.</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Abdominal ultrasound:</span> chronic diffuse liver disease and hepatomegaly, right diffuse renal disease and nephromegaly.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Soft tissue ultrasound:</span> capsular distension with effusion, synovitis in proximal metacarpophalangeal joints compatible with RA.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Liver biopsy: changes in liver architecture, with portal spaces widened by the chronic mononuclear lymphocytic inflammatory process that damaged the limiting plate. Presence of piecemeal necrosis, or interface hepatitis, necroinflammatory foci, mild plasmacytosis, binucleated reactive hepatocytes, disarranged trabeculae (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The findings were consistent with chronic active liver disease.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Symptoms suggestive of SLE were manifest. Thus, we requested an immunological profile that subsequently would corroborate the diagnosis, together with the history of RA and evidence from the soft tissue ultrasound, pointed to the diagnosis of <span class="elsevierStyleItalic">rhupus</span>. Patients with <span class="elsevierStyleItalic">rhupus</span> often present with a diagnosis of RA and, later, develop secondary signs of SLE.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> The clinical symptoms and signs associated with SLE in <span class="elsevierStyleItalic">rhupus</span> are cutaneous photosensitivity, malar rash, alopecia, and hematologic changes such as leukopenia and thrombocytopenia. Renal and neurological involvement are uncommon.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Diffuse liver disease, hypergammaglobulinemia and the presence of anti-smooth muscle antibodies were noteworthy and, given the suspicion of AIH, we requested a liver biopsy. The findings were consistent with interface hepatitis with mononuclear infiltrate, and the simplified criteria for AIH were evaluated<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> and the result was positive, with a score of 7.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The presence of antiphospholipid (aPL) antibodies pointed to the suspicion of aPL syndrome. However, the absence of clinical manifestations or obstetric history ruled it out. Another study found that up to 3% of the patients with autoimmune liver disease had aPL, although this result was not significant.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, the overlap of <span class="elsevierStyleItalic">rhupus</span> and autoimmune hepatitis is an uncommon condition that requires suspicion on the part of the clinician and multidisciplinary management for appropriate treatment.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authorship</span><p id="par0065" class="elsevierStylePara elsevierViewall">EZF and DLO participated in the conception of the article, in its writing and in the critical review of the text. All of the authors approved the article for publication.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authorship" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Zavala-Flores E, Loja-Oropeza D. <span class="elsevierStyleItalic">Rhupus</span> y hepatitis autoinmune: una asociación infrecuente. Reumatol Clin. 2017;13:365–366.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 785 "Ancho" => 1047 "Tamanyo" => 339386 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Piecemeal necrosis with damage to the hepatocytes. Necroinflammatory lesion.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Overlap between systemic lupus erythematosus and rheumatoid arthritis: is it real or just an illusion?" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 6 | 18 |
| 2024 October | 141 | 35 | 176 |
| 2024 September | 95 | 27 | 122 |
| 2024 August | 117 | 50 | 167 |
| 2024 July | 107 | 46 | 153 |
| 2024 June | 92 | 35 | 127 |
| 2024 May | 105 | 30 | 135 |
| 2024 April | 98 | 33 | 131 |
| 2024 March | 98 | 44 | 142 |
| 2024 February | 71 | 24 | 95 |
| 2024 January | 85 | 27 | 112 |
| 2023 December | 71 | 25 | 96 |
| 2023 November | 71 | 31 | 102 |
| 2023 October | 66 | 26 | 92 |
| 2023 September | 94 | 44 | 138 |
| 2023 August | 47 | 13 | 60 |
| 2023 July | 67 | 38 | 105 |
| 2023 June | 84 | 19 | 103 |
| 2023 May | 67 | 22 | 89 |
| 2023 April | 59 | 14 | 73 |
| 2023 March | 83 | 25 | 108 |
| 2023 February | 88 | 20 | 108 |
| 2023 January | 81 | 12 | 93 |
| 2022 December | 70 | 28 | 98 |
| 2022 November | 84 | 26 | 110 |
| 2022 October | 93 | 24 | 117 |
| 2022 September | 62 | 39 | 101 |
| 2022 August | 74 | 33 | 107 |
| 2022 July | 63 | 37 | 100 |
| 2022 June | 83 | 34 | 117 |
| 2022 May | 77 | 45 | 122 |
| 2022 April | 90 | 55 | 145 |
| 2022 March | 109 | 54 | 163 |
| 2022 February | 89 | 30 | 119 |
| 2022 January | 46 | 40 | 86 |
| 2021 December | 63 | 44 | 107 |
| 2021 November | 62 | 51 | 113 |
| 2021 October | 67 | 49 | 116 |
| 2021 September | 60 | 37 | 97 |
| 2021 August | 54 | 40 | 94 |
| 2021 July | 62 | 38 | 100 |
| 2021 June | 75 | 22 | 97 |
| 2021 May | 57 | 50 | 107 |
| 2021 April | 186 | 147 | 333 |
| 2021 March | 103 | 22 | 125 |
| 2021 February | 65 | 30 | 95 |
| 2021 January | 75 | 23 | 98 |
| 2020 December | 72 | 18 | 90 |
| 2020 November | 95 | 19 | 114 |
| 2020 October | 80 | 14 | 94 |
| 2020 September | 40 | 23 | 63 |
| 2020 August | 39 | 21 | 60 |
| 2020 July | 28 | 15 | 43 |
| 2020 June | 44 | 16 | 60 |
| 2020 May | 33 | 13 | 46 |
| 2020 April | 27 | 21 | 48 |
| 2020 March | 24 | 4 | 28 |
| 2018 December | 2 | 0 | 2 |
| 2018 July | 1 | 0 | 1 |
| 2018 May | 6 | 0 | 6 |
| 2018 April | 3 | 1 | 4 |
| 2018 March | 26 | 2 | 28 |
| 2018 February | 78 | 15 | 93 |
| 2018 January | 63 | 27 | 90 |
| 2017 December | 79 | 29 | 108 |
| 2017 November | 58 | 33 | 91 |
| 2017 October | 20 | 20 | 40 |
Show all
