The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis

Takayasu arteritis: clinical importance of extra-vessel uptake on FDG PET/CT

Background

[F-18]fluorodeoxyglucose positron emission tomography/computed tomography is routinely used for assessing Takayasu arteritis patients. However, extra-vessel [F^-18]fluorodeoxyglucose uptake has not been evaluated in detail in these patients. We aimed to describe the extent and distribution of extra-vascular [F-18]fluorodeoxyglucose uptake on positron emission tomography/computed tomography in Takayasu arteritis patients. Seventy-three [F-18]fluorodeoxyglucose positron emission tomography/computed tomography scans from 64 consecutive Takayasu arteritis patients (59 women, mean age, 35.4 years; range, 13 to 71 years) and 40 scans from age-matched controls (36 women, mean age, 37.8 years; range, 13 to 70 years) were examined. We graded [F-18]fluorodeoxyglucose uptake in large vessels using a 4-point scale and evaluated extra-vessel findings. Factors correlated with disease activity were examined. We evaluated the relationship between disease activity according to the National Institutes of Health score with extra-vessel findings, as well as other inflammatory markers (e.g., white blood cell count and C-reactive protein level).

Results

Extra-vessel involvement was present in 50 of 73 (68.4%) scans, specifically at the following sites: lymph nodes, 1.4%; thyroid glands, 17.8%; thymus, 11.0%; spleen, 1.4%; vertebrae, 45.2%; and pelvic bones, 9.6%. Takayasu arteritis patients had higher [F-18]fluorodeoxyglucose uptake in the spine (P = 0.03) and thyroid glands (P = 0.003) than did controls; uptake in other regions was comparable between groups. Compared with inactive patients, those with active Takayasu arteritis had a higher number of [F-18]fluorodeoxyglucose uptake sites in the vasculature (P = 0.001). Finally, patients with a National Institutes of Health score of ≥ 1 had significantly higher extra-vascular involvement (P = 0.008).

Conclusions

Extra-vessel [F-18]fluorodeoxyglucose uptake may be present in the context of Takayasu arteritis-related inflammatory processes. Information on extra-vascular [F-18]fluorodeoxyglucose uptake may be useful for detecting and evaluating inflammatory processes when interpreting positron emission tomography/computed tomography scans obtained from Takayasu arteritis patients.

Imaging acquisition technique influences interpretation of positron emission tomography vascular activity in large-vessel vasculitis

OBJECTIVES

To determine the impact of imaging acquisition time on interpretation of disease activity on ¹⁸F-fluorodeoxyglucose positron emission tomography (PET) in large-vessel vasculitis (LVV) and assess the relationship between clinical features and image acquisition time.

METHODS

Patients with giant cell arteritis (GCA) and Takayasu's arteritis (TAK) were recruited into a prospective, observational cohort. After a single injection of FDG, all patients underwent two sequential PET scans at one and two-hour time points. Images were interpreted for active vasculitis by subjective assessment, qualitative assessment, and semi-quantitative assessment. Agreement was assessed by percent agreement, Cohen's kappa, and McNemar's test. Multivariable logistic regression identified associations between PET activity and clinical variables.

RESULTS

79 patients (GCA  =  44, TAK  =  35) contributed 168 paired one and two-hour PET studies. A total of 94 out of 168 scans (56%) were interpreted as active at the one-hour time point, and 129 scans (77%) were interpreted as active at the two-hour time point (p < 0.01). Associations between clinical variables and PET activity categories (dual inactive, delayed active, dual active) were evaluated. Using multivariable nominal regression, clinically active disease was significantly more common in patients in the delayed active group (Odds Ratio 1.94, 95%CI 1.13-3.53; p  =  0.02) and the dual active group (Odds Ratio 1.71, 95%CI 1.06-2.93; p  =  0.04) compared to the dual inactive group.

CONCLUSIONS

Imaging protocol significantly influences interpretation of PET activity in LVV. A substantial proportion of patients with LVV have PET activity only detected by delayed imaging. These patients were significantly more likely to have concomitant clinically-determined active disease.

Axillobifemoral bypass for total abdominal occlusion secondary to Takayasu's arteritis: A case report

INTRODUCTION

Takayasu's arteritis (TA) is a rare disease that mainly affects large arteries. Approximately 20% of TA patients will require surgical intervention secondary to arterial complications such as intermittent claudication, persistent hypertension refractory to treatment, and heart failure.

PRESENTATION OF CASE

The case of a 22-year-old female with TA of five years of evolution is presented. The patient deteriorated clinically after five years of corticosteroid and immunosuppressant management requiring surgical intervention with an axillobifemoral bypass for a total abdominal occlusion. Onset, pre-surgical and post-surgical Doppler ultrasonography as well as abdominal angiotomographies document and corroborate the patient's clinical and hemodynamic improvement.

DISCUSSION

Very limited literature exists regarding surgical interventions for TA patients. While most reported cases present an endovascular surgical management. Open surgical procedures have lower rates of restenosis than endovascular management. Although endovascular management is less invasive than extra-anatomical axillobifemoral bypass, the patient was not a candidate for endovascular stent graft placement due to the increased risk for vascular injury and subsequent perforation. Approximately a fifth of TA patients are candidates for surgical intervention over time.

CONCLUSION

Vascular surgery in TA cases becomes an option when the patient does not improve clinically after administration of medical treatment. Although endovascular management has fewer complications, the rate of restenosis is higher. Patients at risk of restenosis and who have increased perioperative vascular risk can benefit from open surgical procedures. Surgical management should be tailored to the patient's needs.

YKL-40 as a new biomarker of disease activity in Takayasu arteritis

OBJECTIVE

To evaluate the role of YKL-40 as a biomarker of disease activity in patients with Takayasu arteritis (TA).

METHODS

The study included 40 patients diagnosed with TA between January 2017 and January 2018. 40 age and sex matched healthy controls were included. Serum levels of YKL-40, as well as IL-6, IL-8, IL-17, sCD163, VEGF, MMP-2, MMP-9, OPN, PTX-3 and IFN-γ, were detected at the base line and end of the 6-month follow-up. Modified Kerr criteria, in which MRA was performed instead of traditional angiography, was used a standard measure of disease activity. The association of the measured biomarkers with disease activity was analysed.

RESULTS

The serum levels of YKL-40, IL-6, IL-8, IFN-γ, MMP-2, MMP-9, PTX-3 and OPN were significantly higher in active disease than in inactive disease. Significant differences in the serum levels of YKL-40, IL-6 and PTX-3 were also observed according to the disease activity degree. Logistic analysis demonstrated that high YKL-40 levels and high IL-6 levels were independent risk factors for active disease. When YKL-40 was combined with IL-6, the specificity and sensitivity for detecting active disease were increased (87.6% and 70.4% respectively); similar findings were obtained when YKL-40 was combined with CRP (72.3% and 84.6% respectively). A predictive model of active disease using ESR, CRP, IL-6, PTX-3 and MMP-9 showed significantly improved diagnostic efficiency when YKL-40 was added to the model (sensitivity: 85.1%; specificity: 94.3%; NRI value: 12.4%; IDI value: 4.6%, p < 0.05).

CONCLUSIONS

Serum YKL-40 concentrations may be a useful biomarker of disease activity in TA.

Brachial-Ankle Pulse Wave Velocity is Increased and Associated with Disease Activity in Patients with Takayasu Arteritis

Aim: Takayasu arteritis (TAK) is a rare inflammatory large-vessel vasculitis with increased cardiovascular morbidity and mortality. Brachial-ankle pulse wave velocity (ba-PWV) is a widely used measure of arterial stiffness and serves as an indicator of either cardiovascular risk or severity of vascular damage. However, the studies about the relationship between TAK and ba-PWV are limited. This study aimed to investigate the use of ba-PWV in the patients with TAK.

Methods: Sixty-seven patients with TAK and 67 age and sex matched healthy controls were recruited. Patients with TAK were grouped according to disease activity. The routine hematological parameters and ba-PWV were summarized.

Results: Ba-PWV was significantly higher in the patients with TAK than in the healthy controls (P < 0.001). Ba-PWV was significantly higher in the patients with active TAK than in the patients with inactive TAK (P = 0.04). Multiple liner regression analysis indicated that TAK (β = 363.97, P = 0.013), and mean arterial pressure (MAP) (β = 8.52, P = 0.012) were independently related to ba-PWV. Ba-PWV did not correlate with C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in overall patients with TAK (both P > 0.05). In patients with TAK without immunosuppressive therapy, ba-PWV significantly correlated with CRP (r = 0.419, P = 0.008) but not ESR (P > 0.05). Multiple logistic regression analysis indicated that ba-PWV was an independent predictor of active TAK in overall patients with TAK (OR = 1.003, 95% CI = 1.000–1.007; P = 0.040) and patients with TAK without immunosuppressive therapy (OR = 1.006, 95% CI = 1.001–1.012; P = 0.031).

Conclusions: Being significantly increased in patients with TAK, ba-PWV is significantly associated with TAK disease activity, and it probably correlates with systematic inflammation.

Total Occlusion of Abdominal Aorta in Takayasu Arteritis

Takayasu arteritis is a type of large vessel vasculitis that mainly affects the aorta and its major branches. The disease can have a myriad of manifestations ranging from non-specific symptoms of low-grade fever and weight loss to lower limb claudication. A 21-year-old woman presented with uncontrolled hypertension for the last six months. The CT aortogram revealed total occlusion of the abdominal aorta with collateral vessels formed by the right and left internal mammary artery. We present a case of Takayasu arteritis in a 21-year-old woman with complete obstruction of the abdominal aorta. She was treated only with oral medications. The associated review of the literature is also discussed.

EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice summary

Large vessel vasculitis (LVV) is the most common form of primary vasculitis comprising of giant cell arteritis (GCA), Takayasu's arteritis (TAK) and idiopathic aortitis. Early diagnosis and treatment of LVV are paramount to reduce the risk of ischemic complications such as visual loss and strokes, vascular stenosis and occlusion, and aortic aneurysm formation. Use of imaging modalities [ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT) and [18F]-fluorodeoxyglucose positron emission tomography (PET)] has steadily increased to enable assessment of cranial and extracranial arteries, as well as the aorta. These imaging modalities are less invasive, more sensitive and readily available compared to temporal artery biopsy (TAB). Modern imaging methods have changed the role of TAB in diagnosing GCA and have replaced diagnostic angiography. Over the last two decades, several studies have evaluated the use of US, MRI, CT and PET in LVV. However, these various imaging tools are not yet uniformly used in routine clinical practice and controversy exists as to which imaging modality best provides meaningful assessments of disease activity and damage in LVV. In January 2018, evidence-based recommendations for the use of imaging modalities in LVV were published. The aim of this review is to summarize the current evidence of imaging in patients with or suspected of having LVV, and to highlight the clinical implications of the EULAR recommendations.

Takayasu Arteritis: What Can Go Wrong in The Glomeruli for Large Vessel Vasculitis? A Case Report of an Unusual Cause of Persistent Microscopic Hematuria in a Patient with Takayasu Arteritis

We describe a case of persistent microscopic hematuria in a patient with Takayasu arteritis (TA). Urological cause has been excluded. Classically, TA is found to only involve large arteries like the aorta and its branches. There is some evidence that showed the association of small vessel vasculitis like glomerulonephritis with TA. Histopathological studies showed similar features of vasculitis between the small and large vessel involvement in TA. This may explain the similar disease process that has not been well understood in TA. We believe that the persistent microscopic haematuria in the patient described is caused by TA associated glomerulonephritis. A series of investigations ruled out other causes of glomerular microscopic haematuria like autoimmune or infection related glomerulonephritis.

Comparison of Clinical Features at the Onset of Takayasu's Arteritis According to Age and Sex

BACKGROUND

Takayasu's arteritis (TA) is a large-vessel vasculitis that predominantly affects the aorta, pulmonary artery, and its main branches. The cause of TA is still unclear.

OBJECTIVE

To identify the clinical characteristics of TA at onset in different patient groups.

METHODS

The clinical manifestations, laboratory, and angiographic findings of 53 patients with TA based on age at onset and sex were retrospectively analysed.

RESULTS

The ratio of the incidence of TA in males and females was 1:4. Chest pain, reduced glomerular filtration rate (GFR), and multivessel involvement were the most common symptoms at TA onset in male patients. 17% of patients had an onset age >40 years, and the percentage of TA patients >40 years old with chest pain was significantly higher [6 (66.7%) vs 13 (29.5%) and p=0.031] than that in TA patients <40 years old. However, their renal artery involvement [1 (11.1%) vs 21 (47.7%)), p=0.042], abdominal aorta lesion [0 (0.0%) vs 16 (38.1%), p=0.030], and multiple vessel involvement [2 (22.2%) vs. 32 (72.7%), p=0.004] were significantly less evident. Multivariate analysis showed that hypertension and thoracic aortic lesion were predisposing factors for TA diagnosis [odds ratio (OR)=3.918, 95% confidence interval (CI)=1.616-1566.185, p=0.026]. For patients with aortic insufficiency (OR=3.674, 95% CI=2.734-567.621, p=0.007) or aneurysm formation (OR=7.255, 95% CI=1.23-1628.614, p=0.044), ascending aortic lesion was an independent risk factor. Furthermore, patients >40 years with chest pain but no brachial pulse should be suspected to have TA.

CONCLUSION

Hypertension and thoracic aortic lesion are predisposing factors for the diagnosis of TA. Male with TA was more prone to present with chest pain, multivessel involvement, and reduced GFR.

Biomarkers in Vasculitides of the Nervous System

Besides being affected by the rare and severe primary angiitis of the central nervous system (PACNS) the nervous system is also affected by primary systemic vasculitides (PSV). In contrast to PACNS, PSV affect not only the central but also the peripheral nervous system, resulting in a large array of potential symptoms. Given the high burden of disease, difficulties in distinguishing between differential diagnoses, and incomplete pathophysiological insights, there is an urgent need for additional precise diagnostic tools to enable an earlier diagnosis and initiation of effective treatments. Methods available to date, such as inflammatory markers, antibodies, cerebrospinal fluid (CSF) analysis, imaging, and biopsy, turn out to be insufficient to meet all current challenges. We highlight the use of biomarkers as an approach to extend current knowledge and, ultimately, improve patient management. Biomarkers are considered to be useful for disease diagnosis and monitoring, for predicting response to treatment, and for prognosis in clinical practice, as well as for establishing outcome parameters in clinical trials. In this article, we review the recent literature on biomarkers which have been applied in the context of different types of nervous system vasculitides including PACNS, giant-cell arteritis, Takayasu's arteritis, polyarteritis nodosa, ANCA (anti-neutrophil cytoplasm antibody)-associated vasculitides, cryoglobulinemic vasculitis, IgA vasculitis, and Behçet's disease. Overall, the majority of biomarkers is not specific for vasculitides of the nervous system.

Aortitis and aortic aneurysm in systemic vasculitis

The term "large-vessel vasculitis" refers to chronic inflammation affecting the elastic arteries, mainly aorta and its major branches. Large-vessel vasculitis affecting the aorta is termed as "aortitis." This leads to diffuse wall thickening, loss of elasticity, stenosis, occlusion, dissection, calcification or aneurysm formation. Vasculitis involving the aorta includes Takayasu arteritis (commonest large-vessel vasculitis in India), giant cell arteritis (GCA), the periaortitis spectrum (including inflammatory abdominal aortic aneurysm), rheumatic diseases and IgG4-related disease. It is important for physicians to be aware of the aortic manifestations of common vasculitis-so that clinically relevant aortic involvement is not missed. Also, it is equally important for surgeons to keep in mind that aortic aneurysms can have an inflammatory aetiology. The primary reason for this is the central role that immunosuppressive therapy plays in the management of inflammatory aortic aneurysms. Surgical or percutaneous interventions, when needed, are most likely to succeed when performed after activity control; perioperative steroids may be beneficial in select cases, and postoperative disease activity control is imperative.

Comparative study of 18F-FDG PET/CT and CT angiography in detection of large vessel vasculitis

OBJECTIVE

Compare ¹⁸F-FDG PET/CT and CTangio in the diagnosis of extracraneal large vessel involvement in patients with suspicion of large vessel vasculitis (LVV).

MATERIAL AND METHODS

A retrospective database reviewed 59 patients with clinical suspicion of LVV undergoing ¹⁸F-FDG PET/CT and CTangio. In 55 patients PET/TC and CTangio were done simultaneously in the same machine and in 4 patients with a scan interval of<1 month. PET/CT analyses included qualitatively and quantitative analysis (ratio SUVmax ¹⁸F-FDG vessel/SUVmax liver). CTangio was assessed for concentric mural thickening, contrast wall enhancement and structural vascular changes as potential complications of vasculitis.

RESULTS

¹⁸F-FDG PET/CT and CTangio show high specificity (97.2%) for LVV diagnosis, with an excellent sensitivity for ¹⁸F-FDG PET/CT (95.6%) and lower for CTangio (60.9%), which leads to a high negative predictive value for ¹⁸F-FDG PET/CT (97.2%) and a high false negative rate for CTangio (39.1%). A 70% concordance between ¹⁸F-FDG PET/CT and CTangio was obtained (Kappa index 0.70± 0.095 (P<.001).

CONCLUSION

The results show the greater potential of ¹⁸F-FDG PET/CT for the detection and extension of LVV. Therefore, ¹⁸F-FDG PET/CT should be exploited to the maximum and consider as the first line imaging technique in the extracranial diagnosis of LVV and its possible association with polymyalgia rheumatica. The addition of CTangio could be more indicated in patients with Takayasu arteritis and in long-standing and/or severe vasculitis since it increases the accuracy in the detection of possible vascular complications.

IgG4-aortitis among thoracic aortic aneurysms

Objective

The incidence of aortitis in patients with thoracic aortic diseases is not well established. The aim of this study was to analyse the frequency and clinical course of patients with aortitis in a surgical series.

Methods

320 consecutive patients with ascending aorta/aortic arch aneurysm or acute aortic syndrome who underwent surgery from 2012 to 2017 in a single tertiary referral hospital were retrospectively reviewed. Epidemiological data, clinical course and variables related to diagnosis, treatment and follow-up were collected from patients with histologically proven aortitis.

Results

From 320 examined aortic samples, 279 (87.2%) thoracic aneurysms and 41 acute aortic syndromes (12.8%), 9 (2.8%) were aortitis: 3 cases of Takayasu’s arteritis, 3 of IgG4-related aortitis, 2 of giant cell, and 1 classified as idiopathic. Median age at surgery was 53.4 (51–69.2) years and six cases were female. Seven patients presented with non-specific symptoms and the diagnosis was made at pathology. Surgery was elective in eight patients and emergent in one case of IgG4-related aortitis. 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) was performed for disease extension study and as a monitoring technique during the follow-up of five patients, with just one case performed presurgically. All the patients with IgG4-related disease showed extrathoracic aortic involvement. There were no deaths, neither in-hospital nor during the 1.7 years of median follow-up.

Conclusions

In surgically treated thoracic aorta pathology, the frequency of aortitis is low; IgG4-related disease is among the most common aetiologies with a frequency similar to other types of aortitis, such as Takayasu’s and giant cell arteritis, and clinical manifestations are non-specific making presurgical diagnosis difficult. 18F-FDG PET/CT allows a better assessment of disease extension and therapeutic response. Surgery can be successfully performed and corticosteroid therapy ensures a good mid-term follow-up.

Insufficient Use of Corticosteroids without Immunosuppressants Results in Higher Relapse Rates in Takayasu Arteritis

Objective.

Although prednisolone (PSL) and immunosuppressants are key drugs for Takayasu arteritis (TA) treatment, there is limited evidence on the optimal PSL dose. The aim of this study was to investigate the correlation between the initial PSL dose and relapse in TA.

Methods.

We enrolled 105 patients with TA who satisfied the criteria of the Japanese Circulation Society and American College of Rheumatology from 1990 to 2015. The clinical characteristics and outcomes of patients with TA were retrospectively evaluated. The relapse-free period was assessed according to the difference in initial treatments.

Results.

Relapse was observed in 57 (59.4%) of 96 patients treated with immunosuppressive therapy at diagnosis during a median followup of 56 months. Male sex and younger age of onset were significantly associated with relapse. Although ≤ 30 mg/day PSL monotherapy was preferably prescribed for patients with lower inflammatory markers, compared with > 30 mg/day (87.2% vs 52.6%), a significantly higher relapse rate was observed in the ≤ 30 mg/day group (HR 1.78; p = 0.047). Further, the relapse-free period was longer in patients treated with ≥ 50 mg/day PSL compared with those treated with ≤ 40 mg/day PSL. Combination therapy improved the relapse-free period compared with PSL monotherapy in the short term. The initial PSL dose was not associated with adverse events.

Conclusion.

A higher dose of PSL was associated with a significant decrease in the relapse rate. The effect of combination therapy on relapse needs to be further investigated. Lower-dose PSL monotherapy is an undesirable strategy for remission induction in TA, despite low disease activity.

Pulmonary Artery Involvement in Patients with Takayasu Arteritis

OBJECTIVE

This study was performed to explore the clinical manifestations and longterm prognosis in patients with Takayasu arteritis (TA) with pulmonary artery involvement (PAI).

METHODS

The medical records of 194 patients with TA who underwent traditional catheter angiography or computed tomography of pulmonary artery from 2009 to 2016 were retrospectively reviewed. The clinical manifestations, angiographic features, and mortality of 128 patients with TA with PAI were further analyzed.

RESULTS

Patients with TA with PAI had a higher risk of pulmonary hypertension (PH) than patients with TA alone (61.7% vs 7.6%, p < 0.001). Patients with PAI and PH more frequently developed dyspnea, hemoptysis, and lower limbs edema (all p < 0.05) than those without PH. Patients with PH also had a higher incidence of bilateral PAI (84.8% vs 34.7%, p < 0.001) and a higher pulmonary artery obstruction index [23 (interquartile range 20-27) vs 10 (6-15), p < 0.001]. Left heart disease was presented in 39 (30.5%) patients with TA with PAI. During the median followup of 38 (21-58) months, 19 and 2 deaths occurred among patients with and without PH, respectively. Among patients with PAI, the mortality rate was 7 times higher in patients with than without PH (p = 0.009). Independent predictors of mortality were the disease duration (p = 0.047), New York Heart Association class III/IV (p = 0.019), right ventricular systolic dysfunction (p = 0.019), and respiratory failure (p = 0.007).

CONCLUSION

Patients with TA with PAI have a higher risk of developing PH than patients with TA alone. The presence of PH in patients with PAI increases the risk of early mortality.

[Revascularization of supra-aortic trunks in Takayasu's arteritis]

INTRODUCTION

Takayasu's disease is an inflammatory arteritis mainly affecting the aorta, its main divisional branches and pulmonary arteries. The arterial damage during Takayasu's disease is essentially occlusive and preferentially affects supra-aortic trunks. Indications for revascularization of supra-aortic trunks are clear but results are rarely reported. The purpose of this study was to evaluate the results of supra-aortic trunk revascularization in Takayasu's arteritis.

PATIENTS AND METHODS

We report a retrospective study conducted between 2012 and 2018 about patients with Takayasu's arteritis who underwent revascularization of supra-aortic trunks.

RESULTS

Our series consisted of six patients. All patients were female. The average age was 29 (range 18-48) years. The operative indication was cerebrovascular ischemic symptoms in five patients and intermittent claudication of the upper limb in one. We performed aorto-bi-carotid bypass in four patients, a subclavian artery angioplasty in one and a vertebral artery angioplasty in one. At 1 month, operative mortality was zero and morbidity was marked by hemorrhagic stroke in one patient operated by conventional surgery. The average follow-up was 4 years (1.8). During the follow-up, one patient was reoperated after 18 months for an anastomotic false aneurysm in the ascending aorta. We noted a favorable outcome with total resolution of the symptomatology for the other patients and Doppler ultrasound confirmed patency during follow-up.

CONCLUSION

Surgical revascularization of supra-aortic trunks in Takayasu's arteritis can be associated with a risk of stroke and a risk of anastomotic pseudoaneurysms. Endovascular revascularization appears to be less invasive but its long-term results are rarely reported.

Gender differences in clinical presentation and vascular pattern in patients with Takayasu arteritis

Objective: To compare clinical characteristics and pattern of vascular involvement at disease onset according to gender specificity in patients with Takayasu arteritis (TA).Methods: Data from 117 TA patients (11 male, 106 female), diagnosed according to the American College of Rheumatology criteria, from our centre were retrospectively collected. Differences between men and women regarding demographic features, diagnostic delay, signs and symptoms attributed to TA, and arteries involved at diagnosis were compared. Data were obtained from three published articles describing gender differences in TA. A global analysis of these three cohorts plus ours (a total of 578 patients; 108 men, 470 women) was performed.Results: In our TA cohort, age at disease onset and age at diagnosis were not significantly different between genders. Diagnostic delay was higher in men. Male patients showed higher involvement of iliac arteries (right, p = 0.016; left, p = 0.021); females suffered more frequently from upper limb claudication (p = 0.026). In the overall analysis, men had higher prevalence of arterial hypertension (p = 0.007) and more frequent involvement of abdominal aorta (p = 0.026), renal arteries (right, p < 0.001; left, p < 0.001), and iliac arteries (right, p = 0.009; left, p = 0.002). Women more frequently exhibited upper limb claudication (p = 0.042) and involvement of left subclavian artery (p = 0.005), carotid arteries (right, p < 0.001; left, p < 0.001), and supradiaphragmatic aorta (ascending, p = 0.050; arch, p < 0.001; descending, p = 0.003). Inflammatory markers were more frequently raised in women (p = 0.005).Conclusions: In TA patients, gender has a strong influence on pattern of vascular involvement and consequently on clinical presentation. Specifically, women have a higher involvement of the supradiaphragmatic vessels, whereas in men the abdominal vessels are more frequently affected.

Large-vessel vasculitis diagnosed between 50 and 60 years: Case-control study based on 183 cases and 183 controls aged over 60 years

BACKGROUND

Age at onset of large-vessel vasculitis (LVV) is commonly used to distinguish giant cell arteritis (GCA) and Takayasu arteritis (TA). However, LVV between age 50 and 60 years may be difficult to classify.

METHODS

We conducted a retrospective study including LVV aged between 50 and 60 years at onset (LVV_50-60, cases) and compared them to LVV aged over 60 years (LVV_>60, controls). LVV was defined histologically and/or morphologically. Controls fulfilled ACR 1990 criteria for GCA or presented isolated aortitis.

RESULTS

We included 183 LVV_50-60 and 183 gender-matched LVV_>60. LVV_50-60 had more frequent peripheral limb manifestations (23 vs. 5%), and less frequent cephalic (73 vs. 90%) and ocular signs (17 vs. 27%) than LVV_>60. Compared to LVV_>60, CT angiography and PET/CT scan were more frequently abnormal in LVV_50-60 (74 vs. 38%, and 90 vs. 72%, respectively), with aorta being more frequently involved (78 vs. 47%). By multivariate analysis, absence of cephalic symptoms, presence of peripheral limb ischemia and aorta involvement, and increased CRP level were significantly associated with LVV_50-60 presentation compared to LVV_>60. At last follow-up, compared to LVV_>60, LVV_50-60 received significantly more lines of treatment (2 vs. 1), more frequent biologics (12 vs. 3%), had more surgery (10 vs. 0%), and had higher prednisone dose (8.8 vs. 6.5 mg/d) at last follow-up, CONCLUSION: LVV onset between 50 and 60 years identifies a subset of patients with more frequent aorta and peripheral vascular involvement and more refractory disease compared to patients with LVV onset after 60.

Assessment of disease activity in Takayasu arteritis: A quantitative study with computed tomography angiography

BACKGROUND

Identifying disease activity in Takayasu arteritis (TAK) is challenging. This study aimed to investigate the value of quantitative characterization with computed tomography angiography in the assessment of disease activity in patients with TAK.

METHODS

We retrospectively analysed the data on 162 aortic CT angiography from 140 TAK patients. Patients were categorized based on disease activity according to the National Institutes of Health criteria into two groups: active disease group (n = 65) and inactive disease group (n = 97).

RESULTS

Patients with active TAK had a thicker wall compared with patients with inactive TAK (5.2 ± 2.4 mm vs. 2.5 ± 0.8 mm, p < 0.001). The relative post-contrast enhancement ratio of the thickened wall was higher in active TAK than in inactive TAK (1.5 ± 0.3 vs. 1.1 ± 0.2, p < 0.001). Given a thickness cutoff of 3.3 mm, sensitivity for active-phase TAK was 83.1%, specificity 89.7%, positive predictive value 84.4%, and negative predictive value 88.8%. With a relative post-contrast enhancement ratio cutoff of 1.2, sensitivity for active-phase TAK was 89.2%, specificity 76.3%, positive predictive value 71.6%, and negative predictive value 91.3%. In receiver-operating characteristic curves comparison, maximal wall thickness and relative post-contrast enhancement ratio were superior to C-reactive protein and erythrocyte sedimentation rate for determining active phase disease (p < 0.05).

CONCLUSIONS

Quantitative characterization with CT angiography was a useful tool to assess disease activity in TAK patients. Maximal wall thickness and relative post-contrast enhancement ratio have a high sensitivity and specificity for detecting TAK activity.

Demographic, Clinical, and Radiologic Characteristics of a Cohort of Patients with Takayasu Arteritis

BACKGROUND

Takayasu arteritis is a rare large-vessel vasculitis that predominantly affects females of Asian descent. This retrospective analysis was performed to increase understanding of the epidemiology of the disease in the United States.

METHODS

We performed a retrospective cohort study in 2 tertiary centers. Patients were selected according to the American College of Rheumatology classification criteria for Takayasu arteritis. Data collected included demographic characteristics and details of physical examinations, treatments, and surgical interventions. Data were managed with REDCap (Research Electronic Data Capture) tools.

RESULTS

The study included 57 patients. The female:male ratio was 4.2:1, the median age at diagnosis was 29 years, 61.4% of the patients were Caucasians, and 86% of the patients had stenosis on imaging. Hata V was the most common angiographic classification (37.5% of patients). Vascular interventions were required in 43.9% of patients. The most frequent complications were hypertension (56.1%), renal artery stenosis (28.1%), and aortic insufficiency (19.3%).

CONCLUSIONS

Takayasu arteritis continues to be a rare large-vessel vasculitis. In the United States, it tends to affect predominantly Caucasian females, with cervicobrachial involvement. This cohort reflects the morbidity, multiple interventions, and complications experienced by patients with Takayasu arteritis.

Diffusion-weighted Whole-body Imaging with Background Body Signal Suppression (DWIBS) as a Novel Imaging Modality for Disease Activity Assessment in Takayasu's Arteritis

A 26-year-old woman with Takayasu's arteritis (TAK) experienced back and neck pain during tocilizumab (TCZ) treatment. The levels of C-reactive protein were normal, and ultrasonography revealed no significant changes. Diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) showed signal enhancement in the walls of several arteries. Contrast computed tomography showed arterial inflammation in the same lesion. After increasing the dose of prednisolone and TCZ, all signal enhancements decreased and continued to decrease, as observed on days 76 and 132. Thus, DWIBS may be a novel imaging modality for assessing the disease activity of TAK, particularly during follow-up.

Cardiogenic shock as the first manifestation of large vessel vasculitis in a young patient: case report

Background

Cardiogenic shock secondary to coronary involvement in large vessel vasculitis (LVV) is an unsuspected finding, even more, when no other vascular territories are compromised and when it constitutes the initial clinical manifestation. This case report illustrates a case in which a complete diagnostic study uncovered this aetiology.

Case summary

A 33-year-old woman with cough and chest pain who was diagnosed with acute bronchitis returned with worsening dyspnoea, chest pain, and developed cardiogenic shock. The initial differential diagnoses included myocarditis and takotsubo cardiomyopathy (TCM) owing to a positive troponin I, and echocardiogram with left ventricular dilation, dyskinesia in mid-ventricular and apical segments, systolic dysfunction, and functional mitral regurgitation. A cardiac magnetic resonance showed contractility abnormalities resembling the pattern of TCM but lacked the characteristic myocardial oedema. Subsequently, a coronary angiography expected to result without obstructions showed a critical narrowing of the left main coronary artery. Surgical management consisted of a pericardium patch grafted in the stenotic ostium to restore adequate perfusion. The surgical specimens were sent to the pathology laboratory that reported findings compatible with LVV. Four days after the surgical intervention the patient was discharged alive with a complete recovery of left ventricular systolic function.

Discussion

Chest pain symptoms in a young woman, could be caused by multiple entities, and an ischaemic aetiology from a non-atherosclerotic origin should be kept in mind. A complete study with coronary angiography is crucial to rule out an ischaemic cause even in low-risk groups for atherosclerotic coronary heart disease.

Imaging the Vasculitides

"Neuroimaging plays a vital role in the diagnosis of primary and secondary vasculitic disorders. There multiple neuroimaging options available to accurately describe the underlying clinical deficits of involved cases. Noninvasive neuroimaging modalities provide less risk and when interdigitated, form the basis for a more conclusive understanding of the disease process. There are instances in which invasive cerebral angiography may be needed to image the intricate and at times, small involved vessels. Neuroradiologists should be included in the multidisciplinary team of physicians caring for patients with vasculitides and in research to provide more sensitive and safe modalities for accurate diagnosis."

Certolizumab Pegol Treatment in Three Patients With Takayasu Arteritis

Although glucocorticoids are the mainstay of treatment in Takayasu arteritis (TA), anti-tumor necrosis factor agents are other treatment options in refractory disease. The onset of TA is generally observed in females of reproductive age. Certolizumab pegol (CZP) lacks a fragment crystallizable region and this gives advantage of minimal transfer through the placenta, which makes CZP a safer option in pregnancy. Although there are case reports and trials about use of infliximab, etanercept, and adalimumab in TA, there are scarce data about use of CZP. In this article, we present three TA cases treated with CZP. While two patients benefited from CZP, one patient was refractory to CZP.

Takayasu's arteritis: the retrospective analysis of patients from the Ural population

Takayasu's arteritis (TA) is a rare disease that can be overlooked during the first visit to a GP, rheumatologist, or any other medical specialist due to a variety of its symptoms. The aim of this study was to describe the clinical presentation and the course of patients with TA residing in the Middle Ural. A retrospective analysis was conducted using the medical records of 183 patients treated at the Sverdlovsk Regional Clinical Hospital 1 from 1979 through 2018. The male to female ratio was 1:3. The mean age was 33.5 years for women and 35.2 for men. The most frequently involved arteries were subclavian (101 cases; 55%), carotid (98 cases; 53%) and renal (77 cases; 42%). Type V was the most common angiographic type. Arterial stenosis was present in 94 (51%) patients. Sixty-six patients received surgical interventions. Of all patients included in the analysis, 31 died. The observed 5-year survival was 92%, 10-year survival, 90% and 15-year survival, 80%. Seventy-two patients (39%) developed major adverse cardiovascular events (MACE), including myocardial infarction, ischemic stroke, and thrombosis of large arteries/veins. The clinical presentation of TA may vary in different geographical regions.

PET/CT for Diagnosis and Management of Large-Vessel Vasculitis

PURPOSE OF REVIEW

This review aims to discuss the use of fluorodeoxyglucose (FDG) positron emission tomography (PET/CT) for diagnosis and management of patients with large-vessel vasculitis (LVV).

RECENT FINDINGS

Incidence of LVV is likely underestimated, in part due to its non-specific symptoms. Nevertheless, early diagnosis of LVV is essential to initiate timely therapy in order to prevent vascular complications, such as stenoses and aneurysms. FDG PET/CT imaging has the ability to detect LVV during the acute phase, prior to edema and other vascular structural changes, with its high sensitivity for inflammatory activity. FDG PET/CT was shown to be a powerful prognostic marker by allowing identification of patients at risk of vascular complications. Additionally, preliminary data support the use of FDG PET/CT to follow therapy efficacy. FDG PET/CT allows early detection of inflammation, before morphological and irreversible vascular changes can be observed, allowing prompt diagnosis and treatment of LVV.

Effect of Treatment on Imaging, Clinical, and Serologic Assessments of Disease Activity in Large-vessel Vasculitis

OBJECTIVE

Disease activity in large-vessel vasculitis (LVV) is traditionally assessed by clinical and serological variables rather than vascular imaging. This study determined the effect of treatment on 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) vascular activity in relation to clinical- and serologic-based assessments.

METHODS

Patients with giant cell arteritis (GCA) or Takayasu arteritis (TA) were prospectively evaluated at 6-month intervals in an observational cohort. Treatment changes were made at least 3 months before the followup visit and categorized as increased, decreased, or unchanged. Imaging (FDG-PET qualitative analysis), clinical, and serologic (erythrocyte sedimentation rate, C-reactive protein) assessments were determined at each visit and compared over interval visits.

RESULTS

Serial assessments were performed in 52 patients with LVV (GCA = 31; TA = 21) over 156 visits. Increased, decreased, or unchanged therapy was recorded for 36-, 23-, and 32-visit intervals, respectively. When treatment was increased, there was significant reduction in disease activity by imaging, clinical, and inflammatory markers (p ≤ 0.01 for each). When treatment was unchanged, all 3 assessments of disease activity remained similarly unchanged over 6-month intervals. When treatment was reduced, PET activity significantly worsened (p = 0.02) but clinical and serologic activity did not significantly change. Treatment of GCA with tocilizumab and of TA with tumor necrosis factor inhibitors resulted in significant improvement in imaging and clinical assessments of disease activity, but only rarely did the assessments both become normal.

CONCLUSION

In addition to clinical and serologic assessments, vascular imaging has potential to monitor disease activity in LVV and should be tested as an outcome measure in randomized clinical trials.

Takayasu arteritis - epidemiology, pathogenesis, diagnosis and treatment

Takayasu disease belongs to the group of autoimmune vasculitis which most often affects the aorta and its branches. It is rare, and it mainly affects young women. Recent epidemiologic studies suggest that Takayasu arteritis is being increasingly recognized in Europe. The first symptoms are non-specific and an early diagnosis is difficult and requires clinical awareness and suspicion. Patients with Takayasu arteritis often present increased inflammatory markers, including C-reactive protein and erythrocyte sedimentation rate, but systemic inflammatory response does not always show a positive correlation with inflammatory activity in the vessel wall. Therefore, imaging studies play a principal role in diagnosis and control of the disease. Glucocorticoids remain the most effective and serve as a cornerstone first line treatment. Immunosuppressive drugs play an important role as well, and biological therapy is increasingly being included in the treatment. This article describes the epidemiology, pathophysiology, diagnostics and treatment of this rare disease, so as to alert clinicians because disease left untreated can lead to narrowing and even closure of vital blood vessels. The most common Takayasu arteritis complications include pulmonary thrombosis, aortic regurgitation, congestive heart failure, cerebrovascular events, vision degeneration or blindness, and hearing problems.

Bulgarian rheumatology: science and practice in a cost-constrained environment

Our aim was to appraise publications from Bulgaria, to assess their global impact, and to describe features and challenges unique to the rheumatology practice in Bulgaria characterized by stringent cost constraints. The Scopus database was queried on 25th July 2018 and data on the number of published documents, their Hirsch-indices and citations number were extracted. Published Bulgarian guidelines for the management of rheumatic diseases and the presented data on Bulgarian Rheumatology Society were identified based on prior knowledge of the authors. From all the identified 1082 document the most extensively researched areas were rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), osteoporosis, and osteoarthritis (OA). For the last five years (from Jan 2013 to 25th July 2018) the number of publications was 293. We found that Bulgaria's international scientific collaboration in the field of rheumatology is focused on a handful of countries mainly from Europe. Although Bulgarian rheumatologists have access to costly biologic agents for treating their patients with rheumatic diseases, their funding may not be granted according to the current recommendations of European League against Rheumatism (EULAR) and national guidelines for the management of rheumatic diseases. Although the western world clearly dominates the production of scientific publications in rheumatology, Bulgarian rheumatology may present another perspective for diagnosis and management of patients with rheumatic diseases in a cost-stringent environment. Nevertheless, both rheumatology science and practice in Bulgaria still have a long way to go to take its deserved place among the other European countries.

Statins reduce relapse rate in Takayasu arteritis

BACKGROUND

To investigate the effect of statins on relapse of Takayasu arteritis (TAK), which frequently occurs after achievement of remission.

METHODS

We conducted a retrospective study on TAK patients with active disease, diagnosed between 2012 and 2017. Relapse was defined as recurrence of active disease after achieving remission. Demographic and clinical parameters of patients who experienced relapse were compared to those who did not. To identify factors associated with relapse, significant factors identified in this comparison were included in a multivariate Cox regression analysis. Inverse probability of treatment weighting (IPTW)-adjusted analysis was used to evaluate the influence of statins on relapse.

RESULTS

Of the total 74 TAK patients, 40 (54.1%) patients received statins, whereas 34 (45.9%) patients did not. Relapse was observed in 36 (48.6%) patients of the total 74 TAK patients. Compared with patients who did not experience relapse, patients who experienced relapse were younger (44.5 ± 13.5 years vs 34.1 ± 12.6 years, p = 0.001), had lower prevalence of hypertension (63.2% vs 38.9%, p = 0.037), more commonly had carotidynia (7.9% vs 27.8%, p = 0.025), had higher LDL-cholesterol (84.8 ± 18.8 mg/dl vs 100.5 ± 26.1 mg/dl, p = 0.010), and were less commonly taking statins (71.1% vs 36.1%, p = 0.003). The use of statins was significant in multivariate Cox regression analysis (adjusted hazard ratio 0.260, 95% confidence interval 0.120-0.563, p = 0.001). Furthermore, IPTW-adjusted analysis confirmed that statin use was associated with a lower risk of relapse (IPTW-adjusted hazard ratio 0.153, 95% confidence interval 0.038-0.616, p = 0.008).

CONCLUSION

In TAK, statins can be beneficial in reducing relapse rate after achieving remission.

Malignant Ischemic Stroke in a Young Female: A Rare Primary Manifestation of Takayasu Arteritis

Takayasu arteritis is a rare chronic progressive granulomatous necrotizing large vessel panvasculitis mainly involving aorta and its main branches. It commonly affects the female in second to third decades. Common clinical features of Takayasu arteritis are hypertension, claudication, dizziness, headache, or fever. Takayasu arteritis is diagnosed with clinical history of claudication, absent pulse, discordant blood pressure, bruit over aorta, and typical angiographic findings. Stroke as a primary manifestation of Takayasu arteritis is rarely reported in the medical literatures. We are reporting a 16-year-old female who had malignant ischemic stroke as a first manifestation of Takayasu arteritis.

The Microbiome of Temporal Arteries

Objective

A role for microorganisms in giant cell arteritis (GCA) has long been suspected. We describe the microbiomes of temporal arteries from patients with GCA and controls.

Methods

Temporal artery biopsies from patients suspected to have GCA were collected under aseptic conditions and snap-frozen. Fluorescence in situ hybridization (FISH) and long-read 16S rRNA-gene sequencing was used to examine microbiomes of temporal arteries. Taxonomic classification of bacterial sequences was performed to the genus level and relative abundances were calculated. Microbiome differential abundances were analyzed by principal coordinate analysis (PCoA) with comparative Unifrac distances and predicted functional profiling using PICRUSt.

Results

Forty-seven patients, including 9 with biopsy-positive GCA, 15 with biopsy-negative GCA and 23 controls without GCA, were enrolled. FISH for bacterial DNA revealed signal in the arterial media. Beta, but not alpha, diversity differed between GCA and control temporal arteries (P = 0.042). Importantly, there were no significant differences between biopsy-positive and biopsy-negative GCA (P > 0.99). The largest differential abundances seen between GCA and non-GCA temporal arteries included Proteobacteria (P), Bifidobacterium (g), Parasutterella (g), and Granulicatella (g) [Log 2-fold change ≥ 4].

Conclusion

Temporal arteries are not sterile, but rather are inhabited by a community of bacteria. We have demonstrated that there are microbiomic differences between GCA and non-GCA temporal arteries, but not between biopsy-positive and biopsy-negative GCA.

Shedding light on vasculitis in Egypt: a multicenter retrospective cohort study of characteristics, management, and outcome

OBJECTIVES

The frequency of different vasculitides and their characteristics vary among different regions. The identification of geographic disparities of disease phenotypes helps the development of international criteria, allowing the classification of patients of different ethnicities. This study aimed to describe the frequency, characteristics, course, response to treatment, and outcome of the different adulthood vasculitides in Egypt.

METHODS

This was a multicenter study in which the medical records of adult Egyptian patients diagnosed with vasculitis between 2002 and 2018 were retrospectively reviewed.

RESULTS

The most frequent vasculitides in Egypt were Behçet's disease (76%), hepatitis C virus vasculitis (13.9%), and granulomatosis with polyangiitis (3.9%). Most patients (73.8%) had a major event at the time of diagnosis. Generalized granulomatosis with polyangiitis was more common than the localized type (90% versus 10%, respectively). The aortic arch and its branches were the most common affected sites of Takayasu arteritis. Of vasculitides, Behçet's disease and giant cell arteritis were associated with the greatest rates of relapse (62.7% and 33.3%, respectively). Delayed diagnosis and permanent organ damage were reported in 69.9% and 68.9% of patients, respectively. A low mortality rate was noted (1.3%).

CONCLUSIONS

The most common types of adulthood vasculitides in Egypt are Behçet's disease, hepatitis C virus vasculitis, and granulomatosis with polyangiitis. Major organ involvement is frequent. Delayed diagnosis and permanent organ damage are common.

The Role of Vascular Imaging to Advance Clinical Care and Research in Large-Vessel Vasculitis

Purpose of the Review

The two main forms of large-vessel vasculitis (LVV) are giant cell arteritis (GCA) and Takayasu's arteritis (TAK). Vascular imaging can characterize disease activity and disease extent in LVV. This review critically analyzes the clinical utility of vascular imaging in LVV and highlights how imaging may be incorporated into the management and study of these conditions.

Recent Findings

There are multiple imaging modalities available to assess LVV including ultrasonography, CT angiography (CTA), magnetic resonance angiography (MRA), and ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET). As these techniques are refined, imaging may be increasingly useful to evaluate the cranial arteries and the aorta and its primary branches. In addition, vascular imaging may be useful to monitor disease activity and may have prognostic value to predict future clinical events.

Summary

There are strengths and weaknesses associated with vascular imaging that should be considered when evaluating patients with LVV. Vascular imaging will likely play an increasingly important role in the clinical management of patients and the conduct of research in LVV and may ultimately be incorporated as outcome measures in clinical trials in these conditions.

Pathophysiology of large vessel vasculitis and utility of interleukin-6 inhibition therapy

Takayasu arteritis (TAK) and giant cell arteritis (GCA) affect mainly large- and medium-sized arteries. In refractory cases, vascular remodeling progresses and leads to serious outcomes. Studies have demonstrated that cytokines such as interleukin (IL)-6 play crucial roles in the pathophysiology of TAK and GCA. Recently, randomized controlled trials on IL-6 inhibition therapy using tocilizumab (TCZ) were performed, and significant effects were exhibited. The purposes of conventional treatments have been to improve symptoms and decrease the levels of inflammatory markers. Arterial changes have been considered as damages. However, after TCZ came into practical use, establishment of treat to target is desired to prevent vascular remodeling. In contrast, a combination therapy of glucocorticoids (GCs) and TCZ notably increases the risk of infections. When TCZ is used, careful attention must be paid to possible infections, and dose of GC should be tapered as much as possible. Future tasks are to establish indication and dosage of TCZ, indication for discontinuation of TCZ due to remission, efficacy of TCZ monotherapy, and protocols of TCZ for pediatric cases.

F-18 FDG PET for assessment of disease activity of large vessel vasculitis: A systematic review and meta-analysis

BACKGROUND

The aim of this study is to investigate the performance of F-18 fluorodeoxyglucose positron emission tomography (F-18 FDG PET) or positron emission tomography/computed tomography (PET/CT) for the assessment of disease activity in patients with large vessel vasculitis (LVV) through a meta-analysis.

METHODS

The MEDLINE via PubMed and EMBASE were searched for the studies evaluating the performance of F-18 FDG PET or PET/CT in the assessment of disease activity in patients with LVV. Pooled sensitivity, specificity, diagnostic odds ratios (DORs), and summary receiver-operating characteristic (sROC) curve were estimated across the included studies. Possible publication bias was assessed by Deek's funnel plot asymmetry tests.

RESULTS

A total of 439 PET images from 298 patients pooled from nine studies showed that the pooled sensitivity was 0.88 [95% confidence interval (CI) 0.79-0.93] without heterogeneity (χ2 = 14.42, P = .07) and the pooled specificity was 0.81 (95% CI 0.64-0.91) with heterogeneity (χ2 = 63.72, P = .00) for the detection of active LVV. The pooled DOR was 30 (95% CI 8-107). Hierarchical sROC curve indicates that the area under the curve was 0.91 (95% CI 0.89-0.94). There was no significant publication bias (P = .42), and meta-regression analysis revealed that none of the variables was the source of the study heterogeneity.

CONCLUSIONS

F-18 FDG PET has a good performance for the detection of active disease status in patients with LVV. Revised criteria for the assessment of disease activity incorporated with F-18 FDG PET or PET/CT should be introduced and validated. Further studies are warranted to determine if PET-based treatment of LVV can improve outcomes.

Association of serum high mobility group box 1 levels with disease activity and renal involvement in patients with systemic vasculitis

High mobility group box 1 (HMGB1) is a kind of proinflammatory mediator that acts as an alarmin when released by dying, injured or activated cells. Previous studies have reported that HMGB1 are closely linked to antineutrophil cytoplasmic antibody-associated vasculitis (AAV). The present study aimed to evaluate whether serum HMGB1 levels were associated with systemic vasculitis (VAs).The study population consisted of 51 patients with VAs, 46 patients with essential hypertension (EH) and 46 healthy controls (HC). Thirty-five patients with VAs had in active stage and 16 patients with VAs in an inactive stage. Furthermore, 31 patients with VAs had renal involvement, the other 20 patients were selected for without renal involvement. Serum HMGB1 levels were measured by enzyme-linked immunosorbent assay. Associations between serum HMGB1 levels with clinical and laboratory parameters were analyzed.Serum HMGB1 levels in patients with VAs were significantly higher than in EH and HC (all P < .05), and no difference regarding serum HMGB1 levels could be found between EH and HC (P = .208). Serum HMGB1 levels in VAs patients with active stage were significantly higher than those in HC and VAs patients with inactive stage (all P < .05). Patients with renal involvement and non-renal involvement had increased HMGB1 levels compared with HC (all P < .05). In addition, serum HMGB1 levels were significantly higher in patients with renal involvement compared with non-renal involvement patients (P = .001). Correlation analysis showed that serum HMGB1 levels were positive significant correlated with the Birmingham Vasculitis Activity Score, hypersensitive C reactive protein (Hs-CRP), serum creatinine (Scr) and 24-hour proteinuria (all P < .05). Among the subsets of VAs, serum HMGB1 levels were significantly higher in AAV, polyarteritis nodosa (PAN) and takayasu arteritis (TA) than in HC (all P < .05). More interestingly, serum HMGB1 were significantly higher in patients with PAN compared with AAV and TA patients (all P < .05). Furthermore, there was positive correlation between serum HMGB1 levels and Hs-CRP, Scr, and 24-hour proteinuria in patients with PAN (all P < .05).Serum HMGB1 levels are increased in patients with VAs compared with HC and EH and can reflect the disease activity and renal involvement.

Serum levels of fibroblast growth factor-2 distinguish Takayasu arteritis from giant cell arteritis independent of age at diagnosis

Takayasu arteritis (TAK) and giant cell arteritis (GCA) are two major variants of large vessel vasculitis, and age is a major factor in their differential diagnosis. We sought to determine whether the two diseases exist on the same spectrum. We compared the serum levels of multiple cytokines and chemokines in 25 patients with TAK, 20 patients with GCA, and sex- and age-matched healthy donors for either condition (HD-TAK and HD-GCA). To evaluate the effects of age on the levels of cytokines and chemokines, we performed multiple logistic regression analysis using the least absolute shrinkage and selection operator (LASSO) method. The levels of IL-1RA, IL-10, GM-CSF, G-CSF, FGF-2, eotaxin, and IP-10 were significantly different between TAK and GCA, but no differences were found in the levels of IL-6, IL-12(p40), IL-17, IFN-γ, and TNF-α. Significant differences in the levels of IL-1RA, IL-10, GM-CSF, eotaxin, and IP-10 were observed between the HD-TAK and HD-GCA groups. Multiple logistic regression analysis demonstrated that only FGF-2 and IP-10 could significantly distinguish the diseases when added to age. Multiple logistic analysis using factors selected by the LASSO method revealed that FGF-2 was the only significant factor to distinguish the diseases when added to age. Among numerous cytokines and chemokines analyzed, only FGF-2 could be used together with age at diagnosis to differentiate TAK and GCA. Our results suggested the importance of considering the effects of age on serum cytokines.