Laryngeal
Involvement
in Systemic
Lupus Erythematosus
By Ariel D. Teitel, C. Ronald MacKenzie, Richard Stern, and Stephen A. Paget Laryngeal involvement in systemic lupus ery thematosus (SLE) can range from mild ulcerations, vocal cord paralysis, and edema to necrotizing vasculitis with airway obstruction. In this report, four cases showing the range of severity of this disease manifestation are presented, accompanied by a comprehensive review of the literature. The clinical course of 97 patients with laryngeal involvement with SLE are reviewed, of whom 28% had laryngeal edema and 11% had vocal cord paralysis. In the majority of cases, symptoms such as hoarseness, dyspnea, and vocal cord paralysis resolved with corticosteroid therapy. Other, less common causes of this entity included subglottic stenosis, rheumatoid
T
HE FIRST CASE of laryngeal involvement in systemic lupus erythematosus (SLE) was published more than 30 years ago.’ Since that initial report, additional examples of this often serious complication of SLE have been reported sporadically. The presence of laryngeal involvement is now believed to occur in as many as one third of patients with SLE.2 Despite the frequency and life-threatening potential of this disease manifestation, it remains a clinical observation that probably is not appreciated by many physicians caring for patients with SLE. In this report, we present a comprehensive review of the literature concerning this manifestation of SLE and supplement it with four previously unreported case histories of patients with SLE-related laryngeal involvement. The broad range of pathological entities within the larynx of these patients, the differential diagnosis, and the approach to therapy are discussed. PATIENTS AND METHODS The Hospital for Special Surgery, a 200-bed tertiary referral center located in New York City, has an SLE population of approximately 200 patients who account for 800 average annual patient visits. The four cases described herein all met the American College of Rheumatology criteria for SLE3 and were cared for by one of the authors (cases 1 through 3) or by a current fellow (case 4) at our institution between 1987 and 1991.
nodules, inflammatory mass lesions, necrotizing vasculitis, and epiglottitis. The clinical presentation of laryngeal involvement in patients with SLE follows a highly variable course, ranging from an asymptomatic state to severe, lifethreatening upper airway compromise. With its unpredictable course and multiple causations, this complication remains a diagnostic and therapeutic challenge to physicians involved in the care of patients with SLE. Copyright o 1992 by W. B. Saunders Company INDEX WORDS: Systemic lupus erythematosus; larynx; vocal cord.
Case 1
A 37-year-old black man with newly diagnosed SLE was admitted in April 1987 with fever (40°C) and a several-week history of progressive hoarseness and dysphagia. Laryngoscopy revealed diffuse laryngeal edema and left vocal cord paralysis. The next day, mild respiratory stridor developed and repeat endoscopy showed new areas of edema in the left arytenoid and left aryepiglottic fold. A computed tomography (CT) scan of the neck showed diffuse soft tissue edema; no mass, abscess, or foreign body was seen (Fig 1). Subsequent laryngeal cultures were negative. High-dose intravenous methylprednisolone therapy greatly ameliorated the symptoms. Repeat laryngoscopy 48 hours after the institution of treatment showed markedly diminished edema and normal vocal cord mobility. He has not experienced laryngeal symptoms during the subsequent 5 years of observation, despite the occurrence of multiple exacerbations of his disease. He is currently on dialysis therapy after failing to respond to pulse cyclophosphamide therapy.
From the Department of Medicine and Rheumatology, The Hospital for Special Surgety, New York, NY Address reprint requests to Stephen A. Paget, MD, The Hospital for Special Surgery, 535 E 70 St, New York, NY 10021. Copright 0 1992 by W. B. Saunders Company 0049-0172/92/2203-0007$5.OOlO
Seminars in Arthritis and Rheumatism, Vol 22, No 3 (December), 1992: pp 203-214
203
TEITEL ET AL
Fig 1:
Scan taken at the
level of the false vocal cord (FVC) showing soft tissue swelling with deviation of that structure to the
right.
(ThC), and
The
thyroid
arytenoid
cricoid
(CrC)
(Arc), carti-
lages are indicated.
Case 2 A 26-year-old black man with an l&month history of SLE was admitted in January 1988 with distal leg pain and swelling to rule out deep venous thrombosis. His disease had been previously characterized by malaise, myalgias, arthritis, and discoid lesions. Four months before admission he developed a right popliteal vein thrombosis and was treated with intravenous heparin. Results of tests for the lupus anticoagulant and anticardiolipin antibodies were negative.
Fig 2: level
Scan taken at the of the
true
vocal
cords (TVC) showing intubation. Diffuse soft tissue edema has narrowed
the
laryngeal ventricle (LV) around the tube. The thyroid (ThC) and cricoid (CrC) cartilages are indicated.
Thirty-six hours after admission the patient complained of a sore throat. During the next 5 hours he developed marked tonsillar enlargement, compression of the uvula, and inspiratory stridor which rapidly progressed to total upper airway obstruction. Urgent nasotracheal intubation was life-saving. A CT scan of the neck showed diffuse soft tissue edema with obliteration of airway patency (Fig 2). Broad-spectrum antibiotic and high-dose corticosteroid therapy were instituted, and a tracheostomy was performed. All blood and laryngeal cultures were
LARYNGEAL
INVOLVEMENT
IN SLE
negative, and over the next 4 days the laryngeal swelling resolved. He has had no recurrence of laryngeal symptoms. Case 3
A 29-year-old Hispanic woman had a 6-year history of SLE with focal proliferative glomerulonephritis, nephrotic-range proteinuria, arthritis, leukopenia, thrombocytopenia, seizures, myositis, and vasculitis. In April, August, and October 1988 she received intravenous pulse methylprednisolone therapy for worsening azotemia and proteinuria. In November 1988, fever and progressive stridor developed over a period of several hours, and she was admitted to the hospital. Otolaryngological consultation confirmed the presence of acute epiglottitis and diffuse laryngeal edema. An emergency intubation was performed in the operating room. Broad-spectrum antibiotic and high-dose corticosteroid therapy were administered intravenously, resulting in rapid resolution of the laryngeal and epiglottal inflammation. Laryngeal and blood cultures were negative. She has not subsequently experienced further laryngeal symptoms, despite several exacerbations of the disease manifested by skin vasculitis, pericarditis, and progressive renal failure leading to dialysis. Case 4
A 26-year-old Hispanic women had SLE diagnosed in December 1989 when she presented with arthritis, fever, and hoarseness of 2 months’ duration. She was antinuclear antibody and double-stranded DNA positive with hypocomplementemia. Laryngoscopy showed slight edema of the vocal cords with normal motion. Her symptoms improved rapidly with beclomethasone dipropionate inhaler, potassium iodide, and 30 mg of prednisone per day. She subsequently experienced several episodes of pleuropericarditis. In February 1991 the patient presented with pleuritic pain, arthritis, and pharyngitis of 1 week’s duration. Wheezing but no true stridor was noted on physical examination. Laryngoscopy showed vocal cord edema and hyperemia with good mobility although the epiglottis was normal; a diagnosis of laryngitis with laryngotracheal bronchitis was made. The patient’s pred-
205
nisone dosage was increased from 5 to 30 mg/d, and trimethoprim sulfamethoxazole therapy was started. Laryngeal cultures were negative, and symptoms resolved within 10 days. During a lo-month follow-up, the disease, including the laryngeal manifestation, has been quiescent. REVIEW
OF THE
LITERATURE
Table 1 summarizes the study population, which is composed of 97 patients with laryngeal involvement with SLE. The different denominators reported in the data reflect the fact that some information was not available for all cases. Half of the patients were on corticosteroid therapy at the time of laryngeal involvement (11/22), and laryngeal involvement was not an isolated manifestation of the disease in most cases (21/24). Nearly all patients had established SLE (93/97); however, two with druginduced lupus, one with discoid lupus, and one with isolated vocal cord nodulosis who eventually developed SLE also are included. Hoarseness was the most frequent symptom (17/25), and dyspnea was noted in 14 of 25 patients. Dysphagia was infrequent (2/25), as was odynophagia (3/25). On clinical examination, the most common laryngeal findings were edema (27/97) and vocal cord paralysis (11/97). Oral ulceration was noted in 7 of 25 patients; in 5 patients it was concurrent, while in 4 patients it occurred 10 days to 2 months before the episode of laryngeal involvement. Two patients experienced both concurrent and prior oral ulceration along with laryngeal involvement. Three patients had had a prior episode of laryngeal involvement with increasing disease activity (case 4 and references 4 and 19). Based on our review of the reported literature, laryngeal involvement in SLE can be divided into nine overlapping categories. These groupings, along with a corresponding differential diagnosis, are presented below. Micosal Inflammation
Oral ulceration, laryngeal erythema, and edema were the most common gross clinical findings. Generally these findings resolved rapidly with corticosteroid therapy. Although this response to therapy strongly suggests that the underlying SLE was the cause of the laryngeal process, the clinician should be aware of other
206
TEITEL ET AL
Table 1: Laryngeal involvement
Author Teitel et al
Age hr)/
SLE
Laryngeal
Gender
Features
Disease
37/M
Arthritis; anemia x6 mo; NSAlDs
in SLE Patients
Therapy
Hoarseness; dysphagia;
High-dose MP IV
Outcome RI resolved 48 h later; NR over 3
x1
mo; E; RI; cul-
yr; on dialysis
tureTeitel et al
26/M
18 mo discoid le-
Pharyngitis; sud-
sions; arthritis;
den laryngeal
20 mgld pred-
edema; culture-
AB; high-dose MP; intubation
Resolution of E over 4 d; NR over 2 yr
nisone Teitel et al
29/F
6 yr GN; arthritis; CNS; 8 mg/d MP
Stridor; suddenonset laryngeal
AB; high-dose MP; intubation
edema; culture-
Resolution of E over 4 d; no recurrence over 1 yr; dialysis
Teitel et al
26/F
Smith et alzO
36/F
2 yr arthritis; se-
Pharyngitis x 1 wk;
rositis; 5 mg/d
H; VC; E; ery-
prednisone
thema; culture-;
1 yr hepatitis; skin;
arthritis; 2-3 g/d
Dg Pharyngitis; H x 1 mo; E; slow VC
AB; 30 mg/d prednisone
Unknown dose steroid
Asa
Resolution of Ph; H; no recurrence
Resolution of Ph. H but several recurrences per year
Korbet et all2
51/F
1 mo anemia; ar-
1 wk DOE; H; Rl;
Unknown dose ste-
Resolution of H,
thralgias;
E; arytenoid car-
roid; steam inha-
DOE, Rl over 2
azotemia; GN 60
tilage
lation
wk
mg/d prednisone Gilliam et all6
24/F
1 mo arthritis; U;
1 mo H; S; E of
myositis; GN;
VCs; M; oral ul-
prednisone/CP
cers; culture-
Trach; prednisone; CP
Inflammation on biopsy; resolution of symptoms
Chatelanat et al7
49/M
Discoid LE only
Scarpelli et al1
21/M
1 yr serositis; ar-
H; edema
Unknown
Necrotizing vascu-
Sudden D; facial,
Unable to intubate
Death; possible
xl8yr
litis on biopsy
thritis; GN; un-
laryngeal edema
laryngeal vascu-
known medica-
litis on biopsy
tions Burgess et ala
59/F
Azotemia; anemia;
H; E; U; pharyngeal M; drooling;
NSAID
Feeding tube; trach; steroids
RI
Inflammation on biopsy; H, M, E improved; permanent RI
50/M
Petri et al5
1 yr CNS; GN;
2 wk dysphagia;
prednisone/CPM
AB; IV steroids
Recurrent fever;
pharyngitis;
Nocardia,
hoarseness
lated; SXs re-
iso-
solved Montgomery
et all9
25/F
7 mo on Asa; arthritis; U; leuko-
H; Ph; 0; E;
Involvement
in Systemic
Lupus Erythematosus
By Ariel D. Teitel, C. Ronald MacKenzie, Richard Stern, and Stephen A. Paget Laryngeal involvement in systemic lupus ery thematosus (SLE) can range from mild ulcerations, vocal cord paralysis, and edema to necrotizing vasculitis with airway obstruction. In this report, four cases showing the range of severity of this disease manifestation are presented, accompanied by a comprehensive review of the literature. The clinical course of 97 patients with laryngeal involvement with SLE are reviewed, of whom 28% had laryngeal edema and 11% had vocal cord paralysis. In the majority of cases, symptoms such as hoarseness, dyspnea, and vocal cord paralysis resolved with corticosteroid therapy. Other, less common causes of this entity included subglottic stenosis, rheumatoid
T
HE FIRST CASE of laryngeal involvement in systemic lupus erythematosus (SLE) was published more than 30 years ago.’ Since that initial report, additional examples of this often serious complication of SLE have been reported sporadically. The presence of laryngeal involvement is now believed to occur in as many as one third of patients with SLE.2 Despite the frequency and life-threatening potential of this disease manifestation, it remains a clinical observation that probably is not appreciated by many physicians caring for patients with SLE. In this report, we present a comprehensive review of the literature concerning this manifestation of SLE and supplement it with four previously unreported case histories of patients with SLE-related laryngeal involvement. The broad range of pathological entities within the larynx of these patients, the differential diagnosis, and the approach to therapy are discussed. PATIENTS AND METHODS The Hospital for Special Surgery, a 200-bed tertiary referral center located in New York City, has an SLE population of approximately 200 patients who account for 800 average annual patient visits. The four cases described herein all met the American College of Rheumatology criteria for SLE3 and were cared for by one of the authors (cases 1 through 3) or by a current fellow (case 4) at our institution between 1987 and 1991.
nodules, inflammatory mass lesions, necrotizing vasculitis, and epiglottitis. The clinical presentation of laryngeal involvement in patients with SLE follows a highly variable course, ranging from an asymptomatic state to severe, lifethreatening upper airway compromise. With its unpredictable course and multiple causations, this complication remains a diagnostic and therapeutic challenge to physicians involved in the care of patients with SLE. Copyright o 1992 by W. B. Saunders Company INDEX WORDS: Systemic lupus erythematosus; larynx; vocal cord.
Case 1
A 37-year-old black man with newly diagnosed SLE was admitted in April 1987 with fever (40°C) and a several-week history of progressive hoarseness and dysphagia. Laryngoscopy revealed diffuse laryngeal edema and left vocal cord paralysis. The next day, mild respiratory stridor developed and repeat endoscopy showed new areas of edema in the left arytenoid and left aryepiglottic fold. A computed tomography (CT) scan of the neck showed diffuse soft tissue edema; no mass, abscess, or foreign body was seen (Fig 1). Subsequent laryngeal cultures were negative. High-dose intravenous methylprednisolone therapy greatly ameliorated the symptoms. Repeat laryngoscopy 48 hours after the institution of treatment showed markedly diminished edema and normal vocal cord mobility. He has not experienced laryngeal symptoms during the subsequent 5 years of observation, despite the occurrence of multiple exacerbations of his disease. He is currently on dialysis therapy after failing to respond to pulse cyclophosphamide therapy.
From the Department of Medicine and Rheumatology, The Hospital for Special Surgety, New York, NY Address reprint requests to Stephen A. Paget, MD, The Hospital for Special Surgery, 535 E 70 St, New York, NY 10021. Copright 0 1992 by W. B. Saunders Company 0049-0172/92/2203-0007$5.OOlO
Seminars in Arthritis and Rheumatism, Vol 22, No 3 (December), 1992: pp 203-214
203
TEITEL ET AL
Fig 1:
Scan taken at the
level of the false vocal cord (FVC) showing soft tissue swelling with deviation of that structure to the
right.
(ThC), and
The
thyroid
arytenoid
cricoid
(CrC)
(Arc), carti-
lages are indicated.
Case 2 A 26-year-old black man with an l&month history of SLE was admitted in January 1988 with distal leg pain and swelling to rule out deep venous thrombosis. His disease had been previously characterized by malaise, myalgias, arthritis, and discoid lesions. Four months before admission he developed a right popliteal vein thrombosis and was treated with intravenous heparin. Results of tests for the lupus anticoagulant and anticardiolipin antibodies were negative.
Fig 2: level
Scan taken at the of the
true
vocal
cords (TVC) showing intubation. Diffuse soft tissue edema has narrowed
the
laryngeal ventricle (LV) around the tube. The thyroid (ThC) and cricoid (CrC) cartilages are indicated.
Thirty-six hours after admission the patient complained of a sore throat. During the next 5 hours he developed marked tonsillar enlargement, compression of the uvula, and inspiratory stridor which rapidly progressed to total upper airway obstruction. Urgent nasotracheal intubation was life-saving. A CT scan of the neck showed diffuse soft tissue edema with obliteration of airway patency (Fig 2). Broad-spectrum antibiotic and high-dose corticosteroid therapy were instituted, and a tracheostomy was performed. All blood and laryngeal cultures were
LARYNGEAL
INVOLVEMENT
IN SLE
negative, and over the next 4 days the laryngeal swelling resolved. He has had no recurrence of laryngeal symptoms. Case 3
A 29-year-old Hispanic woman had a 6-year history of SLE with focal proliferative glomerulonephritis, nephrotic-range proteinuria, arthritis, leukopenia, thrombocytopenia, seizures, myositis, and vasculitis. In April, August, and October 1988 she received intravenous pulse methylprednisolone therapy for worsening azotemia and proteinuria. In November 1988, fever and progressive stridor developed over a period of several hours, and she was admitted to the hospital. Otolaryngological consultation confirmed the presence of acute epiglottitis and diffuse laryngeal edema. An emergency intubation was performed in the operating room. Broad-spectrum antibiotic and high-dose corticosteroid therapy were administered intravenously, resulting in rapid resolution of the laryngeal and epiglottal inflammation. Laryngeal and blood cultures were negative. She has not subsequently experienced further laryngeal symptoms, despite several exacerbations of the disease manifested by skin vasculitis, pericarditis, and progressive renal failure leading to dialysis. Case 4
A 26-year-old Hispanic women had SLE diagnosed in December 1989 when she presented with arthritis, fever, and hoarseness of 2 months’ duration. She was antinuclear antibody and double-stranded DNA positive with hypocomplementemia. Laryngoscopy showed slight edema of the vocal cords with normal motion. Her symptoms improved rapidly with beclomethasone dipropionate inhaler, potassium iodide, and 30 mg of prednisone per day. She subsequently experienced several episodes of pleuropericarditis. In February 1991 the patient presented with pleuritic pain, arthritis, and pharyngitis of 1 week’s duration. Wheezing but no true stridor was noted on physical examination. Laryngoscopy showed vocal cord edema and hyperemia with good mobility although the epiglottis was normal; a diagnosis of laryngitis with laryngotracheal bronchitis was made. The patient’s pred-
205
nisone dosage was increased from 5 to 30 mg/d, and trimethoprim sulfamethoxazole therapy was started. Laryngeal cultures were negative, and symptoms resolved within 10 days. During a lo-month follow-up, the disease, including the laryngeal manifestation, has been quiescent. REVIEW
OF THE
LITERATURE
Table 1 summarizes the study population, which is composed of 97 patients with laryngeal involvement with SLE. The different denominators reported in the data reflect the fact that some information was not available for all cases. Half of the patients were on corticosteroid therapy at the time of laryngeal involvement (11/22), and laryngeal involvement was not an isolated manifestation of the disease in most cases (21/24). Nearly all patients had established SLE (93/97); however, two with druginduced lupus, one with discoid lupus, and one with isolated vocal cord nodulosis who eventually developed SLE also are included. Hoarseness was the most frequent symptom (17/25), and dyspnea was noted in 14 of 25 patients. Dysphagia was infrequent (2/25), as was odynophagia (3/25). On clinical examination, the most common laryngeal findings were edema (27/97) and vocal cord paralysis (11/97). Oral ulceration was noted in 7 of 25 patients; in 5 patients it was concurrent, while in 4 patients it occurred 10 days to 2 months before the episode of laryngeal involvement. Two patients experienced both concurrent and prior oral ulceration along with laryngeal involvement. Three patients had had a prior episode of laryngeal involvement with increasing disease activity (case 4 and references 4 and 19). Based on our review of the reported literature, laryngeal involvement in SLE can be divided into nine overlapping categories. These groupings, along with a corresponding differential diagnosis, are presented below. Micosal Inflammation
Oral ulceration, laryngeal erythema, and edema were the most common gross clinical findings. Generally these findings resolved rapidly with corticosteroid therapy. Although this response to therapy strongly suggests that the underlying SLE was the cause of the laryngeal process, the clinician should be aware of other
206
TEITEL ET AL
Table 1: Laryngeal involvement
Author Teitel et al
Age hr)/
SLE
Laryngeal
Gender
Features
Disease
37/M
Arthritis; anemia x6 mo; NSAlDs
in SLE Patients
Therapy
Hoarseness; dysphagia;
High-dose MP IV
Outcome RI resolved 48 h later; NR over 3
x1
mo; E; RI; cul-
yr; on dialysis
tureTeitel et al
26/M
18 mo discoid le-
Pharyngitis; sud-
sions; arthritis;
den laryngeal
20 mgld pred-
edema; culture-
AB; high-dose MP; intubation
Resolution of E over 4 d; NR over 2 yr
nisone Teitel et al
29/F
6 yr GN; arthritis; CNS; 8 mg/d MP
Stridor; suddenonset laryngeal
AB; high-dose MP; intubation
edema; culture-
Resolution of E over 4 d; no recurrence over 1 yr; dialysis
Teitel et al
26/F
Smith et alzO
36/F
2 yr arthritis; se-
Pharyngitis x 1 wk;
rositis; 5 mg/d
H; VC; E; ery-
prednisone
thema; culture-;
1 yr hepatitis; skin;
arthritis; 2-3 g/d
Dg Pharyngitis; H x 1 mo; E; slow VC
AB; 30 mg/d prednisone
Unknown dose steroid
Asa
Resolution of Ph; H; no recurrence
Resolution of Ph. H but several recurrences per year
Korbet et all2
51/F
1 mo anemia; ar-
1 wk DOE; H; Rl;
Unknown dose ste-
Resolution of H,
thralgias;
E; arytenoid car-
roid; steam inha-
DOE, Rl over 2
azotemia; GN 60
tilage
lation
wk
mg/d prednisone Gilliam et all6
24/F
1 mo arthritis; U;
1 mo H; S; E of
myositis; GN;
VCs; M; oral ul-
prednisone/CP
cers; culture-
Trach; prednisone; CP
Inflammation on biopsy; resolution of symptoms
Chatelanat et al7
49/M
Discoid LE only
Scarpelli et al1
21/M
1 yr serositis; ar-
H; edema
Unknown
Necrotizing vascu-
Sudden D; facial,
Unable to intubate
Death; possible
xl8yr
litis on biopsy
thritis; GN; un-
laryngeal edema
laryngeal vascu-
known medica-
litis on biopsy
tions Burgess et ala
59/F
Azotemia; anemia;
H; E; U; pharyngeal M; drooling;
NSAID
Feeding tube; trach; steroids
RI
Inflammation on biopsy; H, M, E improved; permanent RI
50/M
Petri et al5
1 yr CNS; GN;
2 wk dysphagia;
prednisone/CPM
AB; IV steroids
Recurrent fever;
pharyngitis;
Nocardia,
hoarseness
lated; SXs re-
iso-
solved Montgomery
et all9
25/F
7 mo on Asa; arthritis; U; leuko-
H; Ph; 0; E;
