Polyarteritis nodosa after HBsAg hepatitis in a patient undergoing hemodialysis: manifestation and response to therapy

Polyarteritis nodosa developed in one of 34 patients undergoing long-term maintenance hemodialysis with persistent hepatitis B surface antigenemia. Exacerbation of the baseline hypertension and progressive peripheral neuropathy during the recovery phase of hepatitis B surface antigen hepatitis were the initial features. Poor response to aggressive corticosteroid and immunosuppressive therapy in this patient was in contrast to recent experience in patients undergoing long-term hemodialysis and the general population.

Polyarteritis nodosa associated with acute cytomegalovirus infection

A case of polyarteritis nodosa is described in which the onset of the disease was associated with acute infection by cytomegalovirus. Peripheral neuropathy was the predominant clinical feature, and death occurred 4 years after the onset. This is the first recorded case of polyarteritis in which cytomegalovirus is of possible aetiological significance.

Radiologic recognition of extrahepatic manifestations of hepatitis B antigenemia

Extrahepatic manifestations due to an immunologic response to a surface antigen of hepatitis B virus have been identified. These include a serum sicknesslike syndrome and a necrotizing vasculitis. The latter is far more important and in indistinguishable histologically from nonhepatitis related polyarteritis. At least 90 cases have been reported in the decade since 1970, and five are added here. The necrotizing vasculitis syndrome results from fibrinoid necrosis and inflammation of small and medium-sized arterial walls recognizable angiographically by arterial microaneurysms and often by visceral infarction and hemorrhage. Renal failure is common and often associated with pulmonary edema. Gastrointestinal symptoms are a prominent feature due to bowel ischemia. Infarction and perforation are significant causes of morbidity and mortality. Necrotizing vasculitis is also one cause of pancreatitis and of cholecystitis. Plain films, contrast studies, computed tomography, and sonography have been shown to be useful in the recognition of these complications.

[Periarteritis nodosa associated with hepatitis B virus. 42 cases (author's transl)]

HBs antigen was detected by immunodiffusion or radioimmune assay in the blood of 19 out of 42 patients with periarteritis nodosa examined between 1970 and 1978. Histological or biochemical signs of hepatitis were present in 6% of HBs--positive patients and 1% of HBs-negative patients. The incidence of clinical symptoms was similar in both groups, except for multiple neuritis, which was much more frequent in HBs-positive patients (89%) than in HBs-negative patients (52%; p less than 0.001), suggesting a close relationship between neuritis and HBs and HBs antigen. There was a negative correlation between myalgias and skin lesions and the presence of the antigen. The prognosis of periarteritis nodosa was similar in both groups. The course of the disease seemed to be more prolonged in HBs-positive patients, but there was no significant difference in mortality rate.

Hepatitis B as an immune complex disease

Evidence has accumulated which indicates that several of the extrahepatic syndromes associated with HBV infection--the prodromal arthritis-dermatitis syndrome, systemic necrotizing vasculitis, and glomerulonephritis--result from immune complex-mediated injury; however, our understanding of their pathogenesis remains incomplete. Other disorders--essential mixed cryoglobulinemia and polymyalgia rheumatica--have also been linked to HBV, but these associations are more controversial. In most patients with HBV infection, circulating immune complexes are of no pathogenetic importance, but may reflect normal mechanisms for immune clearance of viral antigens. Little insight has been gained into the factors which predispose to immune complex-mediated tissue injury in only a small proportion of patients with type B hepatitis, and few options are available for the management of patients with these extrahepatic disorders. Finally, circulating immune complexes do not appear to contribute to the pathogenesis of liver disease associated with HBV infection.

[Fatal polyarteritis nodosa following Graves' disease (author's transl)]

Polyarteritis nodosa (PAN), with a fatal outcome, developed during the course of a therapeutically controlled Graves'disease. A review of the published literature confirms that two mechanisms may be involved in the onset of PAN in hyperthyroid patients: an immune response, which is probable in the case reported, or a toxic effect related to the treatment of the hyperthyroidism. This case also emphasizes the therapeutical difficulties encountered, in spite of the corticoid and cyclophosphamide associated treatment with plasmapheresis.

Perforation of the small bowel with rheumatoid arthritis

Mesenteric occlusion is a rare and usually fatal complication of rheumatoid arthritis (RA). We report a patient with RA who had an acute condition of the abdomen, with clinical evidence of perforated bowel confirmed by histologic study. The successful result in this case is attributed to early surgical intervention. Additional experience in dealing with this complication of RA is provided.

Cutaneous polyarteritis nodosa associated with Crohn's disease

A 13-year-old white girl with Crohn's colitis developed recurrent erythematous tender cords and nodules in the lower and upper extremities. Histologic examination of subcutaneous nodules of the right arm revealed granulomatous panarteritis of two muscular arteries in the subcutis. The patient's resected colon showed granulomatous transmural colitis without vasculitis. The association between Crohn's disease and cutaneous polyarteritis nodosa is reviewed and emphasis placed on histologic evaluation of suspicious subcutaneous nodules for correct diagnosis.

Onset of polyarteritis nodosa during allergic hyposensitization treatment

In six of 20 consecutive patients with polyarteritis nodosa, the onset of vasculitic symptoms coincided with hyposensitization therapy for presumptive atopic (immunoglobulin E-mediated) respiratory disease. Atopic symptoms had been present for less than three months in half of the patients and over 10 years in the remainder. Active vasculitis persisted in all patients despite immediate cessation of the hyposensitization treatment. Three patients died within eight months. When compared with the 14 other patients with polyarteritis nodosa, those undergoing hyposensitization had significantly greater skin involvement and peripheral blood eosinophilia (p = less than 0.05). Evidence for circulating immune complexes with decreased hemolytic complement, increased cryoglobulins or increased Clq binding was present in both groups. No single allergen was used in all patients, no antiallergen precipitating antibodies were detected and less than 16 mg of allerginic protein had been injected in five of the patients.

Hepatitis B antigen-associated periarteritis nodosa in patients undergoing long-term hemodialysis

Periarteritis nodosa was observed in three of 266 persistent hepatitis B antigen (HBsAg) carriers undergoing long-term hemodialysis; no cases of necrotizing vasculitis occurred among 384 other patients undergoing dialysis having either no or transient antigenemia. Circulating e antigen, but no e antibody, was found in two of these three patients. The serum level of the third component of complement (C3) was normal in two patients and low in the third. Circulating immune complexes were demonstrated in all three patients, using polyethylene-glycol (PEG) precipitation, PEG-C4, and solid phase C1q tests. HBsAg and anti-hepatitis B antibody (HBsAb) were identified in the PEG precipitates using radioimmunoassay and electron microscopy technics. Direct immunofluorescence performed on a muscle biopsy specimen from one patient was positive for HBsAg, but not for immunoglobulin G (IgG), immunoglobulin M (IgM), C3 or C1q. These data support the hypothesis that circulating immune complexes involving HBsAg may be involved in the pathogenesis of periarteritis nodosa.

[Periarteritis nodosa in an addict with a hepatitis B injection (author's transl)]

The authors describe a case of a drug addict with a hepatitis B who was found to have periarteritis nodosa and a nephrotic syndrome. The course was rapidly fatal and autopsy confirmed the diagnosis. This new case questions the hypothesis suggested of possible toxicity of hard drugs (especially the amphetamines) as being an etiological factor for periarteritis nodosa observed in addicts. Hepatitis B virus, which is involved in the etiology of periarteritis nodosa and some nephrotic syndromes (also reported in addicts) is, in fact, very prevalent in users of hard drugs by the parenteral route.

[Hepatitis-B-surface antigen and panarteritis (author's transl)]

A case of an acutely beginning histologically proved panarteritis is described which was initiated by hepatitis B caused by blood transfusions. After one year of steroid therapy the arteritis was no longer seen histologically, Australia-antigen became negative. Terminally the patient developed an apoplexy, renewed gastric bleeding, septicemia with obstructive jaundice, nose bleeding, increasing renal insufficiency, and cardiac failure. The Australia-antigen reappeared in the serum. It could be assumed that the panarteritis had progressed. Immune complexes of Australia-antigen and corresponding antibodies which are deposited in the vascular wall and cause an inflammatory reaction, are being held responsible for the panateritis. They were proved serologically and by immunofluorescence in the vascular wall. In cases of panarteritis of unknown origin Australia-antigen can be found in a high percentage, as was demonstrated by a second case.

Nutritionally induced necrotizing glomerulonephritis and polyarteritis nodosa in pigs

A florid necrotizing glomerulonephritis was found in all 48 pigs that were fed a waste product from the industrial production of the proteolytic enzyme Alcalase NOVO. In addition, three of the animals developed a lesion identical to polyarteritis nodosa. Focal necrosis of the glomeruli was observed in all animals. Electron microscopy showed electron dense deposits at the subendothelial and subepithelial side of the basement membrane of the glomerular capillary wall and in the mesangium. Immunofluorescence microscopy showed IgM in a fine granular pattern in the glomeruli of all 48 pigs. This appears to be the first report on nutritionally induced glomerulonephritis and polyarteritis nodosa in pigs.

Role of immune complexes in rheumatoid polyarteritis

Serial clinical and serological observations were made on a patient with necrotising polyarteritis associated with rheumatoid arthritis. Significant levels of circulating immune complexes, as determined by a C1q binding assay, were observed up to 2 years before the clinical manifestations of polyarteritis but rose abrumptly immediately before and concurrently with the onset of polyarteritis. Concomitant serial determinations of C3, latex fixation titres for anti-immunoglobulin, and patterns of fluorescence of antinuclear antibody afforded insight into the nature of these somplexes, as did clinical and serological response to glucocorticoid and cytotoxic therapy. Our data suggest that the antibody involved in the complex was of the IgG class and capable of complement fixation.

[Spontaneous perirenal haematoma occurring during 1 familial mediterranean fever. 3 cases (author's transl)]

A perirenal haematoma, associated with the presence of renal micro-aneurysms, developed in three patients with periodic syndrome. In one of the cases, the histology of a subcutaneous nodule confirmed the diagnosis of periarteritis nodosa. This emphasies the importance of vascular lesions in familial mediterranean fever.

Arthritis and hepatitis

The evidence relating four clinically distinct rheumatologic syndromes to infection by the hepatitis B virus is reviewed. Acute hepatitis B is not infrequently heralded by a prodromal rash and rheumatoidlike polyarthritis. Chronic active hepatitis B more rarely is associated with transient arthritis or arthralgias. Polyarteritis nodosa may be a manifestation of hepatitis B infection in as many as 40 percent of cases, and recently the syndrome of "essential" mixed cryoglobulinemia has also been linked to infection with this virus. The finding of immune complexes of varying composition, sometimes with the viral antigen or its antibody (or both) contained in both the serum and synovial fluid suggests that these four syndromes are clinical manifestations of immune complex disease resulting from hepatitis B infection.

[Hyperacute periarteritis nodosa complicating Basedow's disease]

The symptoms and the evolution of necrotizing vasculitis vary greatly. The authors illustrate the case of an 18 year old patient with a history of frequent allergic manifestations (urticaria and others) who was found to have, in septembre 1975, a typical case of Grave's disease. During the following 2 months she was treated with an iodide derivative. One year later the clinical signs increased to the point where a treatment associating lugol, carbamizole and propanolol was deemed necessary. Less than 2 months later there developed a polyvisceral disease with oscillating fever, polyarthralgia and necrotizing vasculitis. The plurivisceral nature of the illness was further illustrated by the presence of a hyperreflexia, a glomerulopathy and retinal exsudats. A muscle biopsy revealed the necrotizing vasculitis with granulomas typical of periarteritis nodosa. Cardiac, neurologic and renal complications were responsable for a rapid down-hill course and despite corticoïdes and immunosuppresive drugs, the patient died after a few weeks of treatment. That periarteritis nodosa should complicate the evolution of Grave's disease suggests a connection between the two, very probably immunologic in nature. The role of drugs capable of inducing vasculitis must be explored, especially the iodide derivatives, the antithyroïd medications or their association. Such cases, even though they may be rare, should incite special care in the prescription of antithyroïd drugs in the allergic patient.

[The periarteritis nodosa--diagnosted by angiography. A case with multiple aneurysms (author's transl)]

Periarteritis nodosa is a severe systemic disease which is characterized by an inflammation of the vessel walls and a high incidence of renal involvement. Angiography should be performed immediately when clinical suspicion is aroused. Angiography is superior to the results of skin and muscles biopsy and gives information about the extension of the disease.

Immune complexes of hepatitis B surface antigen in the pathogenesis of periarteritis nodosa. A study of seven necropsy cases

In 7 unselected necropsy cases of clinically diagnosed periarteritis nodosa, the detection of hepatitis B surface antigen (HBsAg) and hepatitis B core antigen (HBcAg) in the cytoplasm and nuclei of hepatocytes indicated an ongoing infection with hepititis B virus (HBV). In all these cases histologic changes found in the liver varied from "minimal" to chronic aggressive hepatitis. In all the cases, deposits of HBsAg, immunoglobulins, beta1C-globulin and C1q were detected in vascular lesions. That these deposits could represent HBsAg-anti-HBs immune complexes was supported by demonstrating their strong binding of guinea pig complement and by the successful elution of all HBsAg and part of the immunoglobulin from these deposits by treatment with buffers known to dissociate antigen-antibody bonds but not with phosphate-buffered saline, pH 7.6 (PBS). Glomerulonephritis associated with these immune complexes was found in 6 cases. The presence of larger masses of HBsAg immune complexes, chiefly in recent insudative and fibrinoid vascular lesions, their lesser amounts in lesions undergoing involution, and their absence from healed lesions strongly suggest that these complexes play a primary role in the pathogenesis of acute vascular damage in periarteritis nodosa.