New approaches to treatment in systemic vasculitis: biological therapies

Although the effectiveness of biological agents in systemic vasculitis is unproven, their introduction heralds a new era of vasculitis treatment. These agents offer the promise of targeted immunotherapies; the possibility of greater efficacy (and fewer side-effects) than conventional vasculitis treatments; and the potential to provide novel insights into the pathophysiology of these diseases-insights that may be gained only by using these agents in humans. Challenges to the investigation of these therapies in the systemic vasculitides exist, but important basic and clinical investigations are already in progress. We review the major issues facing the investigation of biological agents in vasculitis; examine the rationale for believing that biological strategies in vasculitis will be efficacious; identify several candidate targets for biological approaches; and discuss the results to date of early studies. The potential biological targets discussed include cytokines such as tumour necrosis factor; interleukins-1, -6, and -12; interferon-gamma; the co-stimulatory molecules B7-1 and B7-2; and others.

A disease-specific activity index for Wegener's granulomatosis: modification of the Birmingham Vasculitis Activity Score. International Network for the Study of the Systemic Vasculitides (INSSYS)

OBJECTIVE

To refine and validate the Birmingham Vasculitis Activity Score (BVAS) as a disease-specific activity index for Wegener's granulomatosis (WG).

METHODS

Sixteen members of the International Network for the Study of the Systemic Vasculitides (INSSYS) revised the BVAS, with 3 goals: to reduce the redundancy of some component items, to enhance its ability to capture important disease manifestations specific to WG, and to streamline the instrument for use in clinical research. We defined the items and weighted them empirically as either minor (e.g., nasal crusting = 1 point) or major (e.g., alveolar hemorrhage = 3 points). We then validated the new, disease-specific BVAS/WG in 2 simulation exercises and a clinical case series that involved 117 patients with WG.

RESULTS

We removed 38 items from the original BVAS, revised 9 items, and added 7 new items. Correlations between the scores on the BVAS/WG and the physician's global assessment (PGA) of disease activity were high, even when patients in remission were excluded. In the clinical case series, Spearman's rank correlation coefficient between the BVAS/WG and the PGA was r = 0.81 (95% confidence interval 0.73-0.87). The interobserver reliability using intraclass (within-case) correlation coefficients in the 2 simulation exercises was r = 0.93 for the BVAS/WG and r = 0.88 for the PGA in the first and r = 0.91 for the BVAS/WG and r = 0.88 for the PGA in the second. There was no significant observer effect in the scoring of the BVAS/WG or the PGA. The discriminant validity of the BVAS/WG was good: r = 0.73 (95% confidence interval 0.43-0.83).

CONCLUSION

The BVAS/WG is a valid, disease-specific activity index for WG. Tested in simulation exercises and in actual patients, the BVAS/WG correlates well with the PGA, is sensitive to change, and has good inter- and intraobserver reliability. The INSSYS will use the BVAS/WG to assess the primary outcome in a phase II/III trial of etanercept in WG.

"Essential" cutaneous vasculitis: what every rheumatologist should know about vasculitis of the skin

Although the classification of small-and medium-vessel vasculitides involving the skin remains complex and imperfect, a substantial body of knowledge related to cutaneous vasculitis exists. Some components of this knowledge, though beyond the usual purview of rheumatologists, are essential to understanding the vasculitides. The correct interpretation of cutaneous findings combined with a properly performed skin biopsy yields important insights not only into underlying diagnoses, but also into the pathophysiological mechanisms of individual cases. In this review, we discuss a classification scheme for the cutaneous vasculitides, outline the work-up for evaluating patients with these disorders, and describe the essential features of the major categories of skin vasculitis.

Annular leukocytoclastic vasculitis associated with monoclonal gammopathy of unknown significance

Leukocytoclastic vasculitis is a condition characterized by necrotizing neutrophilic inflammation of small dermal blood vessels usually resulting in palpable purpuric lesions. Leukocytoclastic vasculitis may be secondary to a variety of medications and underlying disease processes, including infections, connective tissue disorders, and malignancies. We describe a patient with a monoclonal gammopathy of unknown significance in whom leukocytoclastic vasculitis developed, manifested by a few prominent annular plaques on the lower extremity. The rare association between monoclonal gammopathy of unknown significance and leukocytoclastic vasculitis as well as the unusual annular presentation of the disease in this patient is discussed, and the relevant literature is reviewed.

Immune-mediated inner ear disease

Immune-mediated inner ear disease (IMIED) is a syndrome that includes the subacute onset of sensorineural hearing loss, often accompanied by vertigo and tinnitus. This constellation of symptoms may occur as a primary disorder in which no other organ involvement is evident, or it may complicate certain systemic conditions, including Wegener's granulomatosis, Cogan's syndrome, polyarteritis nodosa, and systemic lupus erythematosus. The precise disease mechanisms remain undefined, largely because of the difficulty obtaining relevant tissue specimens in untreated patients. However, if treated promptly with aggressive immunosuppression, the devastating sequelae of IMIED may be avoided. In this article, we review the pathophysiology, clinical evaluation, diagnostic testing, and therapy of IMIED.

Antiphospholipid antibody syndrome in renal transplantation: occurrence of clinical events in 96 consecutive patients with systemic lupus erythematosus

We report the results of a detailed examination of clinical events associated with the antiphospholipid antibody (aPL) syndrome in 96 consecutive patients with systemic lupus erythematosus (SLE) who underwent renal transplantation between January 1, 1984, and September 1, 1996. Because of the retrospective nature of our study, we developed strict definitions of clinical events considered to be associated with the aPL syndrome. We reviewed all available hospital, clinic, and outside records of the patients with SLE who underwent transplantation at our center during this time period and noted the results of three standard serological tests for aPLs, when available. Mean follow-up of the 96 patients was 62.6 months. Eighty-five of the 96 patients (88.5%) had at least one test for aPLs performed, and 25 patients (29.4%) had at least one abnormal test result. Among these 25 patients, 15 patients (60%) had clinical events associated with aPL syndrome. Ten patients (10.4%) either died of the aPL syndrome or had an aPL-associated clinical event within 3 months of transplantation. Other morbidity from the aPL syndrome in these 15 patients included: thrombotic arteriolar microangiopathy (2 patients), stroke (4 patients), ocular ischemia (7 patients), deep vein thrombosis or pulmonary embolism (6 patients), renal artery or vein thrombosis (4 patients), peripheral ischemia (1 patient), and fetal wastage (3 patients). By comparison, among the 60 patients with normal aPL test results, only 5 patients had clinical events compatible with the aPL syndrome (P < 0.0001 by chi-squared test). aPLs may be associated with significant morbidity and mortality in patients with SLE undergoing renal transplantation. This study is the first attempt to quantify the impact of aPLs on renal transplantation in a large population of patients with SLE. Further investigation of aPLs in SLE patients with end-stage renal disease is required to clarify the risks, benefits, and optimal clinical management of renal transplantation for these patients.

Validity of a vasculitis activity index for systemic necrotizing vasculitis

OBJECTIVE

To establish the validity of an index designed to measure activity in systemic necrotizing vasculitis (SNV).

METHODS

The Vasculitis Activity Index (VAI) was designed to incorporate appropriately weighted clinical measurements that reflect disease activity in SNV. We performed a pilot study to guide the modification and subsequent testing of the initial design. The data necessary to calculate the VAI are direct ratings by a clinical observer of the degree of activity in 9 organ systems and 3 indirect measures of vasculitis activity. These data are recorded on 0-4 visual analog scales. Physician's global assessment (PGA) is used as the "gold standard" measurement of disease activity. The VAI was validated using 2 independent data sets: the questionnaire data set, derived from test case histories ("paper cases") sent to 100 practicing rheumatologists, and the clinic data set, obtained from use of the VAI in 204 regular care visits of 74 patients with SNV.

RESULTS

The VAI correlated highly with the PGA: Pearson's correlation coefficient R = 0.84 (95% confidence interval [95% CI] 0.80-0.88) for the questionnaire data set, and R = 0.92 (95% CI 0.90-0.94) for the clinic data set. The mean of the interobserver coefficients of variation for the test case histories was lower for the VAI than for the PGA (mean difference 0.45; P = 0.002), indicating that the VAI has less interobserver variation than does the PGA. The change in VAI between clinic visits for individual patients correlated highly with the change in PGA (R = 0.88, 95% CI = 0.83-0.91). The VAI data collection form requires about 1 minute to complete, including computation of the score.

CONCLUSION

The VAI is a valid measure of vasculitis activity that correlates highly with the PGA. In addition, the VAI has less interobserver variation than the PGA and has a high level of sensitivity to change over time. Additional testing of the VAI appears warranted.

Adherence of Pseudomonas aeruginosa to inanimate polymers including biomaterials

Cells of Pseudomonas aeruginosa were adhered to polymethyl methacrylate, polyvinyl acetate, polyvinyl chloride, polyhydroxyethyl methacrylate, mixed-acrylic, silicone, and natural latex materials. Planktonic bacteria and bacteria that adhered to the test materials were compared for their uptake of either L-[3,4,5-3H] leucine or [methyl-3H] thymidine during growth in a minimal medium. Leucine incorporation was reduced and thymidine uptake was negligible in adherent bacteria for up to 8 h following primary attachment by which time cells in the planktonic state showed active uptake of both substrates. These reduced uptake periods correlated with lag phases of growth of adherent cells as determined with a sonication-release plate count procedure and analyses of adenosine triphosphate (ATP). The extent of the lag phase of the adherent populations was dependent on initial densities of adhered cells and the nature of the substratum.

Treatment of non-life threatening Wegener's granulomatosis with methotrexate and daily prednisone as the initial therapy of choice

OBJECTIVE

To examine our experience with methotrexate (MTX) and daily prednisone (PRED) as the initial treatment of Wegener's granulomatosis (WG).

METHODS

Between November 1992 and November 1997, we treated 19 patients with non-life threatening WG with the combination of oral weekly MTX (starting at 7.5-10.0 mg/week) and daily PRED (median starting dose 40 mg/day, range 20-60). The MTX dose was increased to 15 mg/week by the end of the first month, and then by 2.5 mg/week until the disease was controlled. We attempted to taper PRED to 20 mg/day by the end of the second month, but did not use alternate day corticosteroids. Before treatment with this regimen, no patient had received previous treatment for WG.

RESULTS

At presentation, the average number of organ systems involved was 3.6. Nine of the 19 patients (47%) had glomerulonephritis, but none had a serum creatinine > 1.2 mg/dl at presentation. Only 37% of the patients were hospitalized at presentation. Seventeen of 19 patients (89%) improved with treatment, and 14 (74%) achieved remission. However, half those who achieved remission suffered relapses, and no patient achieved a durable, complete remission (disease-free status free of all medications). Fifteen patients (79%) were able to taper PRED to < 10 mg/day. Seven of 8 disease relapses responded to increases of MTX and/or PRED. Only one patient developed glomerulonephritis while receiving treatment and required a change of therapy to cyclophosphamide. There were no deaths among patients in this series. Treatment with MTX and PRED was well tolerated: only 2 (11%) of the patients stopped treatment because of side effects (major liver function test abnormalities in both cases). No patient suffered permanent morbidity from MTX treatment.

CONCLUSION

In selected patients with WG, the combination of MTX and daily PRED effectively controls the disease. However, chronic disease courses are the rule with this treatment regimen, and the likelihood of disease relapse is high. In our experience, the use of MTX and PRED in WG was safer than previously described, despite the use of daily corticosteroids.

End-stage renal disease in lupus: disease activity, dialysis, and the outcome of transplantation

Lupus nephritis remains a major cause of morbidity in SLE. Approximately 10% of patients with SLE develop end-stage renal disease (ESRD). In most SLE patients, disease activity diminishes as ESRD approaches. Consequently, the survival of SLE patients on dialysis (both hemo- and peritoneal) appears to be comparable to that of non-SLE patients. However, the role of antiphospholipid (aPL) antibodies in causing dialysis-related morbidity among patients with SLE requires further investigation. In contrast to the outcomes of dialysis, recent evidence suggests that renal transplantation outcomes among SLE patients are inferior to those of non-SLE patients, primarily because of the risk of recurrent lupus nephritis in the allograft and the effect of aPL-related events on transplantation outcomes. Future avenues of investigation should be directed at developing better strategies to manage and prevent these complications.

CNS vasculitis in autoimmune disease: MR imaging findings and correlation with angiography

BACKGROUND AND PURPOSE

MR findings in CNS vasculitis and their correlation with angiography have not been clearly defined. We therefore explored three hypotheses regarding CNS vasculitis associated with autoimmune disease: 1) MR imaging is highly sensitive; 2) a typical MR appearance exists; and, 3) MR and angiographic findings correlate well.

METHODS

We studied 18 patients with CNS vasculitis associated with autoimmune disease, characterized the MR lesions by type, size, number, and location, and correlated the MR findings with those of angiography.

RESULTS

All patients with CNS vasculitis had abnormalities on MR studies. On average, four +/- two lesions per patient were detected on MR images. The lesions were located in the subcortical white matter (n = 20), cortical gray matter (n = 16), deep gray matter (n = 16), deep white matter (n = 9), and cerebellum (n = 9). Only 65% of MR lesions were evident on angiograms; 44% of the lesions revealed on angiograms were detected by MR.

CONCLUSION

MR imaging is sensitive for CNS vasculitis. Lesions attributable to CNS vasculitis in autoimmune disease are distributed nearly equally among cortical, subcortical, and deep gray matter structures. The modest correlation between MR imaging and angiography suggests that the two techniques provide different information about CNS vasculitis and that both types of studies are needed for the complete assessment of damage caused by vascular abnormalities.

Histoplasmosis mimicking vasculitis of the central nervous system

We describe a case of disseminated histoplasmosis that was erroneously diagnosed as central nervous system vasculitis and treated with immunosuppressive therapy. Our case emphasizes the importance of excluding infections before initiating treatment for presumed central nervous system vasculitis. Clinical clues to underlying Histoplasma infections are also discussed.

Outcome of renal transplantation in ninety-seven cyclosporine-era patients with systemic lupus erythematosus and matched controls

OBJECTIVE

To evaluate the effectiveness of renal transplantation in systemic lupus erythematosus (SLE).

METHODS

A total of 97 SLE patients who underwent renal transplantation between January 1984 and September 1996 were selected for study and were matched with a group of non-SLE controls (1 control for each SLE patient) who also received transplants during that period. SLE patients and controls were matched on 6 covariates: age, sex, race, type of allograft (cadaveric versus living-related), number of previous transplants, and year of transplantation. All study subjects received either cyclosporine or FK-506/tacrolimus as part of their immunosuppressive regimen. In a rigorous medical records review, the status of each allograft and the cause of each graft loss was determined. Using a stratified Cox proportional hazards model, the transplantation outcomes of the SLE patients were compared with those of the controls. The effects of 9 individual variables on transplantation outcomes were also examined, and the statistically significant variables were compared in a stratified, multivariate Cox proportional hazards model.

RESULTS

The control group included patients with 20 different causes of end-stage renal disease (ESRD). The mean followup times for the SLE patients and controls were 323 weeks and 320 weeks, respectively. During the followup period, 52 SLE patients and 37 controls lost their allografts. The 1-, 2-, 5-, and 10-year allograft survival probabilities for the 2 groups (SLE versus controls) were as follows: 81.7% versus 88.2% (1-year); 74.7% versus 84.4% (2-year); 45.9% versus 75.0% (5-year); and 18.5% versus 34.8% (10-year). In the multivariate model, the relative hazard of allograft loss associated with SLE as the cause of ESRD was 2.1 (95% confidence interval 1.06-4.06, P = 0.0328). The total number of HLA mismatches, smoking status, and delayed allograft function were also associated with allograft loss in the multivariate model.

CONCLUSION

Compared with matched controls, renal transplant patients with SLE had inferior transplantation outcomes, with more than twice the risk of allograft loss.

Frequency of recurrent lupus nephritis among ninety-seven renal transplant patients during the cyclosporine era

OBJECTIVE

To determine the frequency of recurrent lupus nephritis (LN) in patients with systemic lupus erythematosus (SLE) who underwent renal transplantation.

METHODS

We reviewed the posttransplant clinical course and renal biopsy results in 97 consecutive SLE patients who underwent a total of 106 renal transplantation procedures at our center from January 1984 to September 1996.

RESULTS

There were 81 female and 16 male patients, with a mean age of 35 years. Mean duration of dialysis prior to transplantation was 33.5 months; 9 patients were never dialyzed. In all patients, the disease was clinically and serologically quiescent at the time of transplantation. The mean posttransplantation followup period was 62.6 months. Patients underwent a total of 143 posttransplant biopsies. Nine patients had pathologic evidence of recurrent LN. Six of the patients with recurrence had cadaveric grafts, 2 had living-related grafts, and 1 had a living-unrelated graft. Recurrence occurred an average of 3.1 years after transplantation; the longest interval was 9.3 years and the shortest, 5 days. Histopathologic diagnoses on recurrence included diffuse proliferative glomerulonephritis, focal proliferative glomerulonephritis, membranous glomerulonephritis, and mesangial glomerulonephritis. In 4 patients, recurrent LN contributed to graft loss. Three of the patients with recurrence had serologic evidence of active lupus, but only 1 had symptoms of active lupus (arthritis). Three patients who lost their grafts secondary to recurrent LN underwent second renal transplantation procedures and had functioning grafts at 7, 30, and 35 months, respectively.

CONCLUSION

In the largest single medical center series of renal transplant patients with SLE, recurrent LN was more common than reported in the literature, but was not always associated with allograft loss. Recurrent LN was often present in the absence of clinical and serologic evidence of active SLE.

Management of systemic sclerosis: the art and science

There have been substantial strides in the therapy of systemic sclerosis (SSc) in recent years, particularly in the management of individual organ manifestations. Effective treatments are available for SSc renal crisis and many of the gastrointestinal manifestations of the disease. Raynaud's phenomenon, a nearly universal problem in SSc, also may be effectively managed. Treatment of the pulmonary complications, pulmonary hypertension and interstitial lung disease, remains difficult. Patients with early, diffuse SSc are the best candidates for experimental therapies intended to modify the overall disease process. Most disease-modifying agents have been directed at the fibrotic and inflammatory processes characteristic of SSc and have achieved little success. Future therapies may target mediators of vascular dysfunction in SSc. The success of future therapeutic trials will depend on collaborative efforts between treatment centers.

Two genitourinary manifestations of Wegener's granulomatosis

Genitourinary manifestations of Wegener's granulomatosis (WG) are rare. We report 2 unusual cases of genitourinary WG, one in which the diagnosis was suggested by a cervical biopsy, and one case of recurrent WG presenting exclusively at a genitourinary site while the patient was taking methotrexate for maintenance of remission.

Outcome of renal transplantation in systemic lupus erythematosus

OBJECTIVES

(1) To provide an overview of the world's experience with renal transplantation in systemic lupus erythematosus (SLE), and to consider the most important studies in detail. (2) To examine four specific questions raised by the review, including (a) the frequency of recurrent lupus glomerulonephritis (GN); (b) the effect of pretransplantation dialysis on transplantation outcome; (c) the method of monitoring lupus activity in transplant patients; and (d) the frequency of early graft loss among lupus patients.

METHODS

We performed a MEDLINE search of the world's literature from 1975 to 1997 on the subject of renal transplantation in SLE, using the search terms "lupus," "SLE," "kidney," "renal transplantation," and "outcome." We included in this review 20 original reports that devoted significant attention to the outcome of renal transplantation among patients with lupus.

RESULTS

Of the nine studies that compared the transplantation outcomes of lupus patients with those of transplant patients with other causes of end-stage renal disease, the allograft survival rates were superior in the comparison groups in six, and approximately equivalent in three. The 1-year allograft survival rate of lupus patients with cadaveric renal transplants (CRTs) was 67% in the largest multicenter study, significantly lower than the rate for the other 14 diseases examined (77%; P = .009). In most studies, the lupus groups were significantly younger than their comparison groups, but they frequently included larger percentages of black patients. Lupus patients who received living-related renal transplants (LRRTs) generally had superior graft survival rates compared with those who received CRTs. In the largest single-center report, the 5-year graft survival rate in the cyclosporine era was 89% for LRRTs, compared with 41% for CRTs. Recurrence of lupus nephritis in the allograft is relatively rare, approximately 2%; this estimate is probably low. However, recurrent lupus glomerular nephritis (GN) did not invariably result in allograft failure. Short length of pretransplantation dialysis (i.e., less than 6 months) had no adverse effect on transplantation outcome in 10 of 11 studies that examined the relationship. Pretransplantation serological parameters, such as complement and anti-double-stranded DNA antibody levels, appear to be unreliable predictors of the likelihood of recurrence, and also may be inaccurate measures of disease activity in the posttransplantation period. Finally, 9 of the 20 studies reviewed noted an increased risk of early graft loss among lupus transplant patients, possibly because of an increased frequency of acute injection reactions and thrombotic events associated with antiphospholipid antibodies.

CONCLUSIONS

Despite the fact that many lupus patients have excellent renal transplantation outcomes, substantial evidence indicates that renal transplant patients with lupus do not fare as well as patients with other causes of end-stage renal disease. Lupus patients may be particularly susceptible to adverse events occurring in the first year after transplantation. Further investigation is needed to improve renal transplantation outcomes for patients with lupus.

Ulnar nerve compression at the elbow caused by a prominent medial head of the triceps and an anconeus epitrochlearis muscle

A number of musculo-tendinous variations around the medial epicondyle have been alleged to cause ulnar nerve compression. Subluxation of the ulnar nerve, a "snapping" separate medial head of triceps, a prominent medial head of triceps covering the ulnar nerve, anconeus epitrochlearis, Osborne's band, and the ligament of Struthers have been implicated. We present a case of clearcut compression of the ulnar nerve at two levels just at and posterior to the epicondyle by a tightly applied prominent head of the triceps, and at a more distal level beneath an anconeus epitrochlearis muscle.

Rupture of an anomalous tendon slip as a cause of forearm pain

Rupture of an anomalous tendon slip between the FDS aponeurosis and FDP tendon to the ring finger was found in a young woman's forearm upon surgical exploration after months of forearm pain and disability. Excision of the anomalous slip resulted in quick and and complete recovery.

Sensitivities of noninvasive tests for central nervous system vasculitis: a comparison of lumbar puncture, computed tomography, and magnetic resonance imaging

OBJECTIVE

To determine the sensitivities of lumbar puncture (LP), computed tomography (CT), and magnetic resonance imaging (MRI) for central nervous system (CNS) vasculitis.

METHODS

We reviewed the charts and radiologic studies of 20 patients with angiogram positive CNS vasculitis.

RESULTS

The patients ranged in age from 7-72 years, with a mean of 43.7 +/- 15.5 years. Twelve patients (60%) were women; 8 (40%) were men. Seven had primary angiitis of the CNS (PACNS), 8 had rheumatological illnesses (4 had systemic lupus erythematosus), and 5 had vasculitis due to other diverse etiologies, including 2 who had CNS infections. LP was positive in 8/15 angiographically proven cases, for a sensitivity of 53% [95% confidence interval (CI): 27-79]. The sensitivity of CT was 65% (11/17) (95% CI: 38-86), and that of MRI 75% (12/16) (CI: 48-93). The use of LP plus either CT or MRI was more sensitive than LP alone: for LP and CT, the sensitivity was 92% (11/12) (CI: 62-100), and for LP and MRI, 100% (12/12) (CI: 74-100). The combination of CT and MRI was not more sensitive than either test alone.

CONCLUSION

The sensitivities of LP, CT, and MRI for angiogram positive vasculitis are only modest. CT and MRI may be completely normal in cases of CNS vasculitis when the angiogram is positive. LP and either CT or MRI are of additive benefit in the diagnosis of CNS vasculitis, and should be done before angiography; and, in a patient with both a normal LP and a normal CT or MRI, a CNS angiogram is unlikely to be positive for vasculitis.

An intratendinous epidermoid cyst after trauma

A 55-year-old man with an enlarging mass in the proximal segment of a finger, which had been previously traumatized, had removal of a large epidermoid cyst embedded in the fascicles of a repaired flexor digitorum profundus tendon. This represents the fourth case presented in the English-language literature of intratendinous inclusion cyst, and the only case associated with traumatic tendon damage.

Ulnar neuropathy at the wrist associated with aberrant flexor carpi ulnaris insertion

A 36-year-old man who sustained an industrial hyperextension injury of the wrist complained of dysesthesia and pain in the ulnar nerve distribution, aggravated for months by wrist movement until exploration. The operation revealed an anomalous insertion of the flexor carpi ulnaris tendon disrupting a major portion of the ulnar nerve proximal to the pisiform. the symptoms were relieved completely after neurolysis and modification of the insertion of the tendon.

Electrical hazards associated with electronic monitoring equipment: A case report

Images