Anemia in patients with Wegener's granulomatosis

AIMS

Anemia is commonly observed among patients with chronic kidney disease (CKD). No such information is available for patients with a history of systemic vasculitis.

METHODS

We examined the prevalence of anemia, the response to therapy with erythropoiesis-stimulating agents (ESA), and the association of anemia with the kidney function in clinically stable patients with Wegener's granulomatosis in a retrospective, single-center study.

RESULTS

The mean hemoglobin concentration of 36 patients (mean age: 58 years; 15 female, 21 male; mean duration of disease: 4.6 years) was 13.0+/-2.1 g/dl, and the mean estimated glomerular filtration rate (eGFR) was 41+/-21 ml/min/1.73 m(2). 14 of 36 patients (38.8%) presented with anemia (hemoglobin concentration < 12 g/dl in women, < 13 g/dl in men, or ESA therapy). In patients with a CKD Stage 3 or 4, anemia was present about twice as much as compared to the Third National Health and Nutrition Examination Survey (NHANES III) population. The hemoglobin concentration, however, was not associated with a change of kidney function (p = 0.1578).

CONCLUSIONS

We found a higher prevalence of anemia in patients with Wegener's granulomatosis, as compared to the NHANES III population. The hemoglobin concentrations showed no association with changes of kidney function.

Lessons learnt in the management of Wegener's Granulomatosis: long-term follow-up of 60 patients

OBJECTIVE

To assess all patients with Wegener's Granulomatosis treated in Nottingham, with particular focus on relapse rate and the useful predictors of relapse. We evaluated how well the findings of nasal examination correlated with disease relapse compared to other parameters such as c-ANCA, ESR and CRP. Presenting features, diagnosis, adverse effects of treatment and mortality rate, were also studied.

DESIGN

Retrospective examination of 60 patient notes, diagnosed and treated for Wegener's granulomatosis at Queen's Medical Centre, Nottingham. The mean follow up period was 8.7 years. Relapse was defined as per the European Vasculitis Study criteria.

RESULTS

cANCA is a useful test at presentation for diagnosis but a negative result does not rule out the disease. Those presenting with ENT symptoms alone may have less raised inflammatory markers but similar cANCA titres as patients with multi-system disease. However, at relapse, patients with ENT disease alone have similar levels of inflammatory markers as those with multi-system relapse. Nasal examination was useful at monitoring the presence of disease activity where the nasal lining is affected.

CONCLUSIONS

Signs of intranasal disease in the form of granular tissue, erythema and bleeding to light touch and crusting over granulation tissue are good predictors of disease activity. A raised cANCA, ESR or CRP provide supporting information about disease activity but if they are negative this does not exclude active disease. cANCA levels were as elevated at relapse in patients who had isolated nasal symptoms and signs as in those with evidence of systemic disease. Low relapse rates were found possibly due to prompt and rigorous initial immunosuppression even in limited disease. This seemed to lead to less progression of patients to multi-system disease and hence a low mortality rate of 5%.

The upper thoracic spinal cord compression as the initial manifestation of Wegener's granulomatosis: a case report

There are only a few reported cases about spinal cord involvement with Wegener's granulomatosis (WG) in the literature. In these cases, the spinal cord is usually indented or compressed by dural and meningeal masses which are characterized by necrotizing granuloma formation and vasculitis. And, it usually cannot be correctly diagnosed. A 53-year-old woman suffered from Wegener's granulomatosis, in whom the upper thoracic spinal cord compression is the initial manifestation. The surgical biopsy and thoracic laminectomy were performed and the histologic examination was done. This patient was finally diagnosed as WG when the pathologic examination revealed as Wegener's granulomatosis and the serum antineutrophil cytoplasmic antibodies (ANCA) were reported positive; titers of antimyeloperoxidase (MPO) antibodies were markedly elevated. After treatment with cyclophosphamide and corticosteroids this patient partially recovered from neurological involvement. In a case such as this, careful monitoring of clinical parameters is essential for assessing disease activity with repeated MRI if neurologic status changes. Serial measurement of ANCA titers may also be helpful to establish the diagnosis. Cyclophosphamide and corticosteroids are the agents of choice for induction of remission of WG.

Functional defect of circulating regulatory CD4+ T cells in patients with Wegener's granulomatosis in remission

OBJECTIVE

Accumulating data support the role of regulatory T cells, a subset of CD4+ T cells that expresses CD25(high) and the transcription factor forkhead box P3 (FoxP3), in controlling and preventing autoimmunity. In Wegener's granulomatosis (WG), an autoimmune vasculitis, up-regulation of CD25 on circulating CD4+ T cells has been observed, even in patients in remission. The objective of this study was to test whether the frequency and/or function of Treg cells from WG patients in remission are disturbed.

METHODS

Peripheral blood mononuclear cells were freshly isolated from 52 WG patients in remission and from 27 age- and sex-matched healthy control subjects. The proportion of circulating Treg cells was assessed by flow cytometry using CD4, CD25, FoxP3, and CD45RO markers. Anergy and suppressive function of CD25(high),CD4+ T cells were determined using polyclonal stimulants and coculture assay in 10 WG patients in remission and in 10 age- and sex-matched healthy controls.

RESULTS

In WG patients, a significant increase was observed in the percentage of circulating CD25(high),CD4+ and CD25(low),CD4+ T cells, whereas CD25-,CD4+ T cells were decreased, as compared with healthy controls. Among circulating CD4+ T cells, an expanded percentage of Treg cells (CD25(high),FoxP3+) with memory phenotype was present in WG patients. However, when the suppressive function of CD25(high),CD4+ T cells was tested, CD25(high),CD4+ T cells from WG patients showed diminished or absent suppression of responder T cell proliferation. The impaired suppression was not due to responder cell resistance (as shown by crisscross experiments with T cells from healthy controls) or altered survival of Treg cells.

CONCLUSION

These data indicate that WG patients in remission have an expanded proportion of Treg cells that are functionally defective. This observation may be relevant to the development and relapsing course of this autoimmune vasculitis.

Seasonal variations in onset of Wegener's granulomatosis: increased in summer?

OBJECTIVE

Investigators have reported significant seasonal variations of onset of Wegener's granulomatosis (WG), but those data were not confirmed by others. We reexamined the hypothesis of a seasonal pattern of onset of WG.

METHODS

We conducted telephone interviews with 59 patients with newly diagnosed WG fulfilling the American College of Rheumatology criteria. Patients were identified having been enrolled from 2001 to 2004 by French hospitals in 2 multicenter therapeutic trials. The interviews investigated precisely how and when their disease had appeared to establish an index date, defined as the year and month of the first symptom(s) attributable to WG. Once telephone interviews had been completed, index dates were also retrieved from medical records.

RESULTS

Among the 59 patients interviewed, 14 (24%) were unable to specify an exact month of WG onset. Based on the remaining 45 "informative" patients, the month of onset distribution varied significantly (p = 0.03, exact goodness-of-fit chi-square test), notably with a higher onset rate in August (p = 0.001). Seasonal distributions also differed significantly (p = 0.01), with an increased rate of summer onset (June-August) (p = 0.001). Index dates extracted from medical files showed that onset was also more frequent in summer (p = 0.01).

CONCLUSION

Our results confirm the seasonality in onset of WG, but unlike previous reports indicating an increase in winter, instead suggest that this vasculitis preferentially appears in summer. These findings might support an allergic mechanism in the pathogenesis of WG.

Antineutrophil cytoplasmic antibodies

Much like other autoantibodies (eg, anti-double stranded DNA in systemic lupus erythematosus or antiglomerular basement membrane antibodies in Goodpasture's syndrome), antineutrophil cytoplasmic antibodies (ANCA) have provided doctors with a useful serological test to assist in diagnosis of small-vessel vasculitides, including Wegener's granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome, and their localised forms (eg, pauci-immune necrotising and crescentic glomerulonephritis). 85-95% of patients with Wegener's granulomatosis, microscopic polyangiitis, and pauci-immune necrotising and crescentic glomerulonephritis have serum ANCA. ANCA directed to either proteinase 3 or myeloperoxidase are clinically relevant, yet the relevance of other ANCA remains unknown. Besides their diagnostic potential, ANCA might be valuable in disease monitoring. In addition, data seem to confirm the long-disputed pathogenic role of these antibodies. Present treatments for ANCA-associated vasculitis are not free from side-effects and as many as 50% of patients relapse within 5 years. Accurate understanding of the key pathogenic points of ANCA-associated vasculitis can undoubtedly provide a more rational therapeutic approach.

Respiratory system involvement in systemic vasculitides

The respiratory system may be involved in all systemic vasculitides (SV), although with a variable frequency. Lung disease is a very common and important feature of the antineutrophil cytoplasmic antibodies (ANCA)-associated SV (AASV), such as Wegener's granulomatosis (WG), Churg-Strauss syndrome (CSS), and microscopic polyangiitis (MPA). In WG, almost all patients have either upper airway or lower respiratory tract disease. Solitary or multiple nodules and masses are the most common findings on chest radiograph. Asthma is a cardinal symptom of CSS, often preceded by allergic rhinitis, frequently complicated by nasal polyposis and sinusitis. Pulmonary transient and patchy alveolar infiltrates are the most common radiographic findings. In MPA, diffuse alveolar hemorrhage (DAH) due to alveolar capillaritis is the most frequent manifestation of the respiratory involvement, clinically expressing with hemoptysis, respiratory distress and anemia. However, DAH may be subclinical and has to be suspected when chest radiograph demonstrates new unexplained bilateral alveolar infiltrates, in the face of falling hemoglobin levels. In giant cell arteritis, the most frequent respiratory symptom is cough, usually non-productive, persistent, and responsive to corticosteroids. In Takayasu arteritis, pulmonary involvement is frequently subclinical and detectable by non-invasive techniques. Pulmonary involvement is rare in polyarteritis nodosa, Kawasaki disease, Henoch-Schönlein purpura and cryoglobulinemic vasculitis. In conclusion, the involvement of the respiratory system is a very common and important feature of AASV, whereas is less frequent in other SV. It comprises a wide spectrum of clinical features and radiological findings, and may have a prognostic significance. The assessment of the respiratory system should be included in the work-up of all patients with SV, especially of those with AASV.

Colour duplex sonography of finger arteries in vasculitis and in systemic sclerosis

CASE REPORTS

Three patients-two with Wegener's granulomatosis and one with an overlap syndrome of rheumatoid vasculitis, systemic lupus erythematosus, and antiphospholipid syndrome-are described. All patients experienced a sudden onset of Raynaud's phenomenon or acrocyanosis when they had a flare of their disease.

DISCUSSION

Ultrasonography (US) showed dark (hypoechoic) arteries without colour signals, resembling the US pattern of embolism. In contrast, US in patients with systemic sclerosis is entirely different, delineating a smaller artery lumen, reduced pulsation, and thickened, slightly hyperechoic artery walls.

Urine IgM excretion predicts outcome in ANCA-associated renal vasculitis

BACKGROUND

Renal function at diagnosis is a strong predictor not only of renal survival but also of patient survival of those with anti-neutrophil cytoplasmic antibody (ANCA)-associated small vessel vasculitis (ASVV). Apart from the renal function at diagnosis, there are no other established risk factors for renal outcome in ASVV. We have previously reported that in other forms of glomerular diseases, an increased urine excretion of IgM is an early marker of poor renal outcome.

METHODS

In this single-centre observational study, the prognostic significance of urine IgM excretion and other selected prognostic markers was studied in 83 consecutive patients (49 males, 34 females) with ASVV with renal involvement.

RESULTS

Patient survival at 1 and 5 years was 93 and 77%, respectively, and the corresponding figures for renal survival censored for death were 84 and 76%. Univariate analysis indicated that patient survival was inversely associated with age, male sex, serum creatinine, low serum albumin and high urine IgM excretion. Renal survival was inversely associated with serum creatinine, albuminuria and urine IgM. Multivariate analysis determined that only old age and high urine IgM excretion were independent predictors of patient survival [odds ratio (OR) = 11.2 and 4.4, respectively, P<0.01]. Urine excretion of IgM was the only independent predictor of end-stage renal disease (OR = 19.8, P = 0.004). Overall, 35% of the patients reached the composite end-point of either death or renal replacement therapy. Urine IgM excretion was the most potent single predictor of such an outcome (OR = 7.7, P = 0.000).

CONCLUSION

The occurrence of an increased amount of IgM in urine at presentation is a strong marker of poor prognosis for patients with ANCA-associated renal vasculitis.

Wegener's granulomatosis

Wegener's granulomatosis is a systemic vasculitis of unknown etiology with a predilection for the respiratory tract and kidneys.

Wegener's granulomatosis: a view from the granulomatous side of the disease

Although the airway granulomata in Wegener's granulomatosis were stressed initially by Friedrich Wegener himself, in the last few decades systemic lesions mainly caused by acute vasculitis have received the most attention. However, recently, the implication of granulomatous manifestations in WG has raised much interest. The present data suggest that an aberrant Th1-type response might play a role in the initiation of WG, clinico-pathologically characterized by granulomatous inflammation rather than vasculitis. Disease progression to generalized WG with the predominance of vasculitic manifestations is associated with a "switch" or further complexity of the collective T cell response with the appearance of another subset of Th2-type cells and a less prominent Th1-type cytokine production in the granulomatous lesions of the upper respiratory tract. However, the clinical significance of the granulomatous inflammation is not yet completely understood. Further research will also have to focus on the role of the granulomata during relapsing disease. We review present knowledge of granulomatous inflammation in WG. Morphologic aspects, the scale of cytokine alterations as well as the variety of clinical manifestations are discussed.

Current status of outcome measures in vasculitis: focus on Wegener's granulomatosis and microscopic polyangiitis. Report from OMERACT 7

The complexity of assessing disease activity, disease status, and damage in the vasculitides reflects the multisystemic pathologic manifestations of these often chronic illnesses. Major progress has been made in the past decade in the development of validated and widely accepted outcome measures for use in clinical trials. Over time, these tools have been regularly revised, expanded, and supplemented with new measures of disease prognosis and damage. As a result clinical research in this area has become increasingly complex. This article critically reviews the current status of tools for assessing disease activity and damage in "ANCA-associated" vasculitides (Wegener's granulomatosis and microscopic polyangiitis), summarizes the current level of validation of each measure, addresses central problems and controversies to be considered during development of new vasculitis assessment tools, and proposes a series of research agendas for consideration by the vasculitis research community.

Successful pregnancy in untreated limited Wegener's granulomatosis

A thirty four year old female presented with upper and lower respiratory symptoms in the third trimester of pregnancy. After the delivery of a healthy baby, the symptoms progressed to involve multiple organ systems and eventually a diagnosis of limited Wegener's Granulomatosis (Carrington-Liebow syndrome) was made. The extremely rare combination of WG and pregnancy, especially the onset of disease in late pregnancy is discussed. The successful outcome of pregnancy even without treatment of WG is the highlight of the case.

Vasculitis in the Geriatric Population

Vasculitis represents an uncommon but important group of disease entities that may affect older patients. The most common systemic vasculitic disease in humans is giant cell arteritis, a disease process seen almost exclusively in patients over the age of 50. Vasculitic disease in geriatric patients presents unique challenges with regard to diagnosis and treatment. A thorough understanding of the vasculitic disease entities that may affect older patients as well as their diagnosis and management is essential in minimizing disease and treatment related morbidity and mortality.

Estudio clínico-biológico y radiológico de la granulomatosis de Wegener en un hospital universitario

Wegener's granulomatosis is a rare systemic vasculitis that fundamentally affects the kidney and respiratory tract. Although the histological findings are very characteristic, they do not occur in all cases, which makes diagnosis difficult.

METHODS

The main clinical, biological and radiological characteristics of 13 cases of Wegener's granulomatosis diagnosed in a university hospital of the center of Spain are collected in this present paper.

RESULTS

The majority of the patients were men in their 50's. Fever and general syndrome were usual presentations of the disease. Upper respiratory tract (10 cases) and lung involvement (9), followed by renal involvement (8), were the most common. Alveolar infiltrates and bilateral nodules were the most common findings in the X-ray and thoracic CT scan, although the latter permits a greater definition of the lesions. Measurement of antibodies against cytoplasma of the neutrophils (ANCA) was positive in 8 patients (6 cANCA and 2 pANCA). Renal biopsy was used most for the histologic diagnosis, where focal and segmental glomerulonephritis was the most common finding. The majority of the patients received steroids plus cyclophosphamide as induction treatment.

CONCLUSIONS

Wegener's disease is a rare systemic vasculitis. The existence of hematuria or respiratory tract involvement in a patient with fever suggests the diagnosis. Conducting a CT scan and ANCAs measurement are useful tools for its diagnosis, since the histology is not definitive.

Echocardiographic features of atrial myocarditis with giant cells: A case report

We report a case of restrictive cardiomyopathy in which a distinct endothelial thickening of the atrial wall and pulmonary vein orifices was noted on transesophageal echocardiography. Echocardiographically guided endomyocardial biopsy of the thickening revealed an inflammatory infiltrate that was rich in giant cells and provided important clues about an underlying immune mechanism for the pathogenesis. Positive results from the antineutrophil cytoplasmic autoantibody assay supported the diagnosis of Wegener's granulomatosis. After immunosuppressive therapy, the endomyocardial thickening completely resolved, but the restrictive cardiomyopathy did not reverse.

Tracheal and central bronchial aerodynamics using virtual bronchoscopy and computational fluid dynamics

Virtual bronchoscopy reconstructions of the airway noninvasively provide useful morphologic information of structural abnormalities such as stenoses and masses. In this paper, we show how virtual bronchoscopy can be used to perform aerodynamic calculations in anatomically realistic models. Pressure and flow patterns in a human airway were computed noninvasively. These showed decreased pressure and increased shear stress in the region of a stenosis.

Wegener granulomatosis in childhood and adolescence

Wegener granulomatosis (WG) is a necrotising granulomatous small vessel vasculitis with a clinical predilection for involvement of the upper airways, lungs and kidneys, which occurs at all ages. The aetiology of WG, like other primary systemic vasculitides, remains unknown. Existing evidence suggests an autoimmune inflammatory process, characterised by early lesions with neutrophils and endothelial cells as active participants and involvement of antineutrophil cytoplasmatic antibodies (ANCA) directed against proteinase-3 (PR3). However, other concomitant factors like infections and environmental factors also appear to be necessary for the development of WG. In addition, multiple genetic factors seem to be involved in disease susceptibility. Whereas the first publications on WG in childhood were based on case reports, some studies in recent years allow to compare clinical findings, disease course, morbidity and mortality rates for childhood and adult onset patients. Whereas most aspects of WG are similar at all ages, some features appear to be significantly different. WG in childhood is more frequently complicated by subglottic stenosis and nasal deformity while treatment-related morbidity and malignancies are less common compared to adults. Introduction of combined treatment with cyclophosphamide and glucocorticoids resulted in a dramatic improvement of patient outcome; however, commonly occurring disease relapses and the risk of chronic organ damage at all ages make long-term follow-up of all patients and the establishment of new therapeutic regimens necessary.

Use of Extracorporeal Membrane Oxygenation in a Patient With Diffuse Alveolar Hemorrhage

Extracorporeal membrane oxygenation (ECMO) was developed as a supportive therapy for severe respiratory failure. It has been shown to be life-saving in neonates and children with isolated respiratory failure, however, its usefulness in adults remains controversial. We report the successful use of ECMO in an adult patient with severe hypoxemic respiratory failure secondary to diffuse alveolar hemorrhage from Wegener granulomatosis.

The Th1 and Th2 paradigm in ANCA-associated vasculitis

In the pathogenesis of anti-neutrophil cytoplasm antibodies (ANCA)-associated vasculitis, T cell contribution is indicated by T cell-dependent ANCA production combined with the presence of T cells in inflammatory infiltrates. However, the exact pathogenic role of T cells in ANCA-associated vasculitis remains to be determined. The Th1/Th2 concept is useful for understanding T cell involvement in pathological processes. This review focuses on T cells and particularly the Th1/Th2 paradigm in ANCA-associated vasculitis. Most research has been done in Wegener's granulomatosis, where a shift in T cell response, from a Th1 pattern in localized disease towards a Th0/Th2 pattern in generalized disease, appears to occur. Although less thoroughly studied, data in Churg-Strauss syndrome and microscopic polyangiitis indicate that these diseases are predominantly associated with Th2 patterns. Further studies elucidating the true nature of the polarization towards Th1 or Th2 in ANCA-associated vasculitis are clearly needed.