Adult-Onset Still’s Disease: Is This Truly a Diagnosis of Exclusion?

Caleb W. Anderson MD; Phalgoon A. Shah MBBS; and Jefferson R. Roberts MD

Abstract Adult-onset Still’s Disease is a rare, idiopathic, inflammatory disorder char- His disease was atypical as it remained refractory for over eigh- acterized by arthralgia, evanescent, salmon-colored rash, and daily teen months to treatment with nonsteroidal anti-inflammatory as well as lymphadenopathy, pharyngitis, splenomegaly, , and drugs (NSAIDs), oral disease modifying antirheumatic drugs serositis. The inciting etiology of this syndrome is unknown, though it has (DMARDs) (except for prednisone), TNF-alpha agents, and been hypothesized that triggers an autoimmune response. The anakinra. A disease flare over one year into treatment was as- Yamaguchi Criteria, the most sensitive and widely used diagnostic criteria, sociated with repeat fourfold rise in coxsackie B titer, though requires both a minimum set of criteria to be met as well other potential etiologies to be excluded. By definition, evidence of concomitant infection, he definitively responded to initiation of tocilizumab several malignancy, vasculitis, or connective tissue disease precludes the diagnosis months after this flare. It has been hypothesized that an infec- of Adult-onset Still’s Disease from being made. We present a very rare case tious etiology initiates a cascade of immunological insults which of a patient who met all diagnostic criteria for Adult-onset Still’s Disease, had results in the clinical syndrome of AOSD. Investigators in the a protracted course refractory to numerous immunosuppressant treatments, past have demonstrated persistence of viral antigens in patients and also had evidence of coxsackie B infection with fourfold rise in viral titers with AOSD, thus raising the question of antigenic stimulation on two occasions (both associated with disease flare). Although coxsackie B driving the ongoing immune response.3,4 We present the follow- has been linked to Adult-onset Still’s Disease at disease presentation, this case is unique in its protracted course and serological evidence of infection ing case of a patient with classic AOSD and elevated coxsackie temporally related to disease flare. While accepted diagnostic criteria call for B viral titers on two separate occasions (both associated with this disease to be a diagnosis of exclusion, our case supports the fact that increased disease activity) as further evidence that continuing ongoing infection may in fact be an important antigenic driver in persistent antigenic stimulation is a driving force in refractory disease, and refractory Adult-onset Still’s Disease. and that AOSD may not truly be a diagnosis of exclusion.

Keywords Case Still’s Disease, Adult-Onset/diagnosis A 29-year-old previously healthy Puerto Rican man presented with pharyngitis (culture negative), chills, and knee pain. The Introduction patient was empirically treated with doxycycline followed by Adult-onset Still’s disease (AOSD) is a rare, idiopathic, in- azithromycin though his symptoms continued to worsen. He flammatory disorder characterized by arthralgia, evanescent, was admitted to inpatient care at that time and was noted to salmon-colored rash, and quotidian or double quotidian fevers. have documented to 39.4C, an evanescent rash of the Lymphadenopathy, pharyngitis, splenomegaly, myalgias, and se- inner thighs which spread to his arms and chest, myalgias, rositis are also commonly seen with this disease. Frequently seen arthralgias with joint effusion, and pleuritic with laboratory abnormalities include leukocytosis, transaminitis, an echocardiogram showing pericardial effusion. Labs were elevated ferritin levels, increased acute phase reactant concentra- notable for elevated CRP to 32mg/L, ESR greater than 100mm/ tions, and aberrant production of proinflammatory cytokines.1 hr, negative ANA/RF, leukocytosis, transaminitis, ferritin of While the inciting etiology of this syndrome is unknown, both 3596 mcg/L, and elevated coxsackie B viral titre (B4 1:160, and bacteria have been isolated in patients with AOSD drawn 11 days into his illness). leading to the hypothesis that infection triggers an autoimmune The patient’s diagnosis was initially unclear as he met four response. A number of different diagnostic criteria have been major and three minor Yamaguchi criteria in the setting of published, with the most sensitive and widely used being the elevated coxsackie B viral titers. He was initially started on Yamaguchi Criteria.1,2 However, this set of criteria requires both naproxen 500mg twice daily to which he responded well, a certain number of major and minor criteria to be met as well though with residual symptoms for which he was switched to other potential etiologies to be excluded, as demonstrated in prednisone 40 mg/day. A coxsackie B viral panel drawn ten Table 1.2 Thus, by definition, evidence of concomitant infection, days after the initial panel demonstrated fourfold increase of malignancy, vasculitis, or connective tissue disease precludes coxsackie B3 from 1:40 to 1:160, with continued elevation of B4 the diagnosis of AOSD from being made. at >1:160, as demonstrated in Table 2. The patient’s symptoms We present a rare and interesting case in which a patient met initially responded to high dose prednisone with decrease in all major criteria and three of the four minor criteria (and later ESR to 5mm/hour 121 days after disease onset. coxsackie B titer in his disease met the fourth minor criteria), yet had proven drawn 151 days after disease onset showed decreasing B3 and coxsackie B viral infection with fourfold rise in antibody titer. B4 serotypes, as demonstrated in Table 2. He was definitively

HAWAI‘I JOURNAL OF MEDICINE & PUBLIC HEALTH, NOVEMBER 2017, VOL 76, NO 11, SUPPLEMENT 2 3 Table 1. Yamaguchi Criteria Table 2. Coxsackie B Viral Titers Major Criteria Minor Criteria Serotype Day 11 Day 21 Day 151 Day 471 Fever >39°C of one week or longer Coxsackievirus B1 Ab <1:10 <1:10 <1:10 <1:10 Arthralgia or arthritis of greater than 2 weeks Lymphadenopathy Coxsackievirus B1 Ab <1:10 <1:10 <1:10 <1:10 Typical Rash Hepatomegaly/Splenomegaly Coxsackievirus B1 Ab 1:40 1:160 1:10 1:160 Leukocytosis >10,000/mm3 Abnormal liver function tests Coxsackievirus B1 Ab 1:160 >1:160 1:80 >1:640 Exclusion Criteria Negative antinuclear antibody and RF Coxsackievirus B1 Ab 1:10 1:40 <1:10 >=1:640 Coxsackievirus B1 Ab <1:10 <1:10 <1:10 <1:10 Malignancies Other rheumatic disease

Figure 1. Extensive Synovitis and Soft Tissue Swelling of Left Hand.

diagnosed with AOSD at this time, though he suffered recurrent tocilizumab in combination with methotrexate which led to an fevers and arthralgia/synovitis upon cessation of steroids. He extended disease remission that has persisted for over two years was tried on various courses of DMARDs to include plaquenil, despite complete steroid taper. colchicine, methotrexate, and adalimumab, though his symptoms always returned after prolonged discontinuation of prednisone. Discussion Fifteen months after disease onset he was hospitalized a second Adult onset Still’s disease is a rare, multisystem inflammatory time with recurrent fevers, myalgias, synovitis of left hand/ disorder characterized by arthralgia, evanescent, salmon-colored wrist, and new lymphadenopathy as demonstrated in Figures rash, and daily fevers. While the true etiology and pathology of 1 and 2. Coxsackie panel drawn at that time was notable for the disease process is not well defined, it is likely multifactorial over fourfold increase of B3 (1:160) and B4 (>1:640). Biopsy and the result of complex interplay between host factors and of the lymph node showed only reactive hyperplasia (Figure antigenic insults.1 The immunopathogenic mechanism of this 3). He was started on etanercept upon discharge, though he was disease can be seen with elevated levels of proinflammatory cy- still unable to wean from prednisone and was thus switched tokines such as tumor necrosis factor-alpha, interferon-gamma, to anakinra, though elevated inflammatory markers and large interleukin-1 (IL-1), interleukin-6 (IL-6), and interleukin-18.5,6 joint arthritis requiring intra-articular steroid injection per- Given the abrupt onset of symptoms and high fever, an in- sisted through this treatment. The patient was finally tried on fectious etiology has been postulated. A study in Nijmegen,

HAWAI‘I JOURNAL OF MEDICINE & PUBLIC HEALTH, NOVEMBER 2017, VOL 76, NO 11, SUPPLEMENT 2 4 Figure 2. PET Avid Left Inguinal Lymph Node, SUV 7.9 Measuring 9mm

Figure 3. Germinal Center from Left Inguinal Node Biopsy Sample Demonstrating Reactive Follicular Hyperplasia.

Netherlands evaluated for potential infectious etiology through mydia pneumonia, Campylobacter jejuni, and Mycoplasma broad serological evaluation in five patients with AOSD. Two pneumoniae have also been implicated.6,8,9,10 of the cases were thought to be secondary to rubella reinfection Coxsackie B virus, an consisting of an icosahedral (based upon high IgG titres) while the disease in a third patient capsid surrounding a single-stranded RNA genome, is a well was attributed to Echovirus 7 as supported by positive culture known cause of febrile arthritis.11 Acute coxsackie viral infec- from a throat swab as well as four-fold antibody titer increase.7 tion is oftentimes indistinguishable from AOSD, and there have Another study evaluated 19 children with chronic rheumatic been few reports discussing the presence of coxsackie infection disease and isolated rubella virus from the lymphoreticular cells in patients ultimately diagnosed with Still’s disease. One study of seven of these patients, including one with Still’s Disease.3 from 1983 evaluating three patients with febrile arthritis found Other implicated viruses include , Epstein-Barr elevated but stable coxsackie B antibody titer in two patients virus, parainfluenza, parvovirus B19, human immunodeficiency and a fourfold rise in viral titer in a third patient.12 A study virus, , B, and C virus, adenovirus, human herpes from 1986 found significant rise in neutralizing antibody to virus 6 and coxsackie B virus. Bacterial infectious agents to coxsackie B4 virus in two patients with evanescent macular rash, include Yersinia enterocolitica, Chlamydia trachomatis, Chla- constitutional symptoms, high spiking fever, and polyarthritis/

HAWAI‘I JOURNAL OF MEDICINE & PUBLIC HEALTH, NOVEMBER 2017, VOL 76, NO 11, SUPPLEMENT 2 5 synovitis. Both patients also had elevated inflammatory markers, Disclaimer transaminitis, and neutrophilic leukocytosis.13 A case of Still’s The views expressed in this abstract/manuscript are those of disease and elevated initial titers to coxsackie B2 and B4 with the authors and do not reflect the official policy or position of progression to hemophagocytic syndrome was described in a the Department of the Army, Department of Defense, or the 12-year-old girl in New Zealand in 1985.14 US Government. Our case is unique in the prolonged and refractory nature of the disease with elevated coxsackie B titers noted twice during Conflict of Interest the course, both times temporally associated with increased None of the authors identify a conflict of interest. disease activity. These findings support either coxsackie viral Authors’ Affiliation: reinfection or viral persistence/chronic infection as an antigenic Tripler Army Medical Center, Honolulu, HI 96859 driver to the immune dysregulation inherent to AOSD. Persistent enteroviral infection has been implicated in several chronic Correspondence to: Phalgoon Shah MBBS; Department of Medicine, Tripler Army Medical Center, diseases to include insulin-dependent diabetes mellitus, dilated 1 Jarrett White Road, Honolulu, HI 96859; Email: [email protected] cardiomyopathy, chronic inflammatory myopathy, and chronic 11,15 fatigue syndrome. This has been shown in both humans as References well as animal models. Persistence of coxsackievirus B3 was 1. Efthimiou P, Paik PK, Bielory L. Diagnosis and management of adult onset Still’s disease. Ann Rheum Dis. 2006 May;65(5):564-72. noted in both the acute and chronic phase of in an 2. Yamaguchi M, Ohta A, Tsunematsu T, Kasukawa R, Mizushima Y, Kashiwagi H, Kashiwazaki immunocompetent mouse model.16 Another study evaluating S, Tanimoto K, Matsumoto Y, Ota T, et al. Preliminary criteria for classification of adult Still’s disease. J Rheumatol. 1992 Mar;19(3):424-30. eight patients with chronic fatigue syndrome and positive en- 3. Chantler JK, Tingle AJ, Petty RE. Persistent rubella virus infection associated with chronic teroviral sequences by PCR were evaluated for viral persistence arthritis in children. N Engl J Med. 1985 Oct31;313(18):1117-23. 4. Newkirk MM, Lemmo A, Commerford K, Esdaile JM, Brandwein S. Aberrant cellular localization at a five-month interval. Four of the eight patients were found of rubella viral genome in patients with adult Still’s disease–a pilot study. . 1993 to have an identical nucleotide sequence in both samples, which 16(1)39-43. 17 5. Cipriani P, Ruscitti P, Carubbi F, Pantano I, Liakouli V, Berardicurti O, Giacomelli R. Tocilizumab was indicative of viral persistence as opposed to reinfection. for the treatment of adult-onset Still’s disease: results from a case series. Clin Rheumatol. 2014 While no study has directly addressed persistence of coxsackie Jan;33(1):49-55. 6. Fautrel B. Adult-onset Still disease. Best Pract Res Clin Rheumatol. 2008 Oct;22(5):773-92. virus in patients with AOSD, a previous study from 1994 found 7. Wouters JM, van der Veen J, van de Putte LB, de Rooij DJ. Adult onset Still’s disease and viral that AOSD patients carry a four-fold greater load of rubella infections. Ann Rheum Dis. 1988 Sep;47(9):764-7. 8. Pouchot J, Sampalis JS, Beaudet F, Carette S, Décary F, Salusinsky-Sternbach M, Hill RO, viral genome than do normal controls, and that the genome is Gutkowski A, Harth M, Myhal D, et al. Adult Still’s disease: manifestations, disease course, found primarily in monocytes and B cells. This suggests the and outcome in 62 patients. Medicine (Baltimore). 1991 Mar;70(2):118-36. 9. Pouchot J, Ouakil H, Debin ML, Vinceneux P. Adult Still’s disease associated with acute human possibility that patients suffering from AOSD may be unable to parvovirus B19 infection. Lancet. 1993 May 15;341(8855):1280-1. effectively clear viral infection from their mononuclear cells.4 10. Perez C, Artola V. Adult Still’s disease associated with Mycoplasma pneumonia infection. Clin Infect Dis. 2001 Mar 15;32(6). While our case is unique in describing elevated coxsackie viral 11. Tam PE, Weber-Sanders ML, Messner RP. Multiple viral determinants mediate myopathogenicity titers temporally associated with increased disease activity, it in coxsackievirus B1-induced chronic inflammatory myopathy. J Virol. 2003 Nov;77(21):11849- 54. does not definitively prove the presence of coxsackie infection 12. Hurst NP, Martynoga AG, Nuki G, Sewell JR, Mitchell A, Hughes GR. Coxsackie B infection as neutralizing antibody titer against coxsackie B virus lacks and arthritis. Br Med J (Clin Res Ed). 1983 Feb 19;286(6365):605. 13. Roberts-Thomson PJ, Southwood TR, Moore BW, Smith MD, Ahern MJ, Geddes RA, Hill WR. specificity. Viral culture or PCR would have offered more defini- Adult onset Still’s disease or coxsackie polyarthritis? Aust N Z J Med. 1986 Aug;16(4):509-11. tive evidence of infection. Also, nucleotide sequence by PCR 14. Heaton DC, Moller PW, Still’s disease associated with Coxsackie infection and haemophagocytic syndrome. Ann Rheum Dis. 1985 May; 44(5): 341-344. would have been useful in determining whether the patient had 15. Feuer R, Mena I, Pagarigan R, Slifka MK, Whitton JL. Cell cycle status affects coxsackievirus persistent infection versus reinfection at the time of his disease replication, persistence, and reactivation in vitro. J Virol. 2002 May;76(9):4430-40. 16. Klingel K, Hohenadl C, Canu A, Albrecht M, Seemann M, Mall G, Kandolf R. Ongoing enterovirus- flare. induced myocarditis is associated with persistent heart muscle infection: quantitative analysis of virus replication, tissue damage, and inflammation. Proc Natl Acad Sci 1992 89:314–318. 17. Galbraith DN, Nairn C, Clements GB. Evidence for enteroviral persistence in humans. J Gen Conclusion Virol. 1997 Feb;78 ( Pt 2):307-12. While previous reports have associated AOSD with infectious triggers, there have been relatively few reported cases of con- comitant coxsackie B infection. This case is unique in reporting a four-fold rise in coxsackie B antibody titers on two separate occasions during a prolonged, refractory course of AOSD, both temporally associated with disease flare. Previous literature has established that coxsackie B can persist in a number of chronic infections, though this has not been proven with AOSD. While the low specificity of viral titers in our case cannot prove the link between coxsackie infection and increased disease activity in AOSD, it supports that evidence of coxsackie B infection should potentially be considered an antigenic driver of AOSD rather than an exclusion criteria.

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