The spectrum of vasculitis: clinical, pathologic, immunologic and therapeutic considerations

Disseminated vasculomyelinopathy in the peripheral nervous system mediated by immune complexes (ICs). Immunohistochemical studies of sciatic nerves in chronic serum sickness (CHSS) in rabbits

Histological examination of 20 sciatic nerves from rabbits with experimental chronic serum sickness (CHSS) revealed patchy vasculitis of the vasa nervorum of various intensity. The vessel lesions ranged from endothelial proliferation to vessel wall necrosis with fibrinoid degeneration and infiltration by lymphocytes, plasma cells, macrophages and, sporadically, by neutrophils. Perivascularly, there were oedema, chronic infiltrates or small haemorrhages. The myelinated fibres in close relation to the vascular system were focally depleted and features of perivascular demyelination were found. Teased fibres showed paranodal and segmental demyelination, axonal degeneration and, sporadically, remyelination. In all cases, immunofluorescent deposits of bovine serum albumin (BSA), IgG and C3 complement were found in and around some vasa nervorum. Other indirect evidence for immune complex (IC) deposition was provided by ultrastructural examination where vascular and endoneurial osmophilic deposits were found; in 4 cases with paracrystalline organization resembling cryoglobulin component. IC-mediated vasculitis led to blood-nerve barrier impairment and leakage of serum proteins into the endoneurial space. The morphological and immunohistochemical changes in this model which develop after a latency period of 2 or more weeks, strongly resemble those observed in human acquired inflammatory demyelinating polyradiculoneuropathies or in connective tissue diseases.

Myeloma, paraproteinemias, and the skin

This review focuses on those systemic diseases or syndromes associated with monoclonal plasma cell disorders that may present with important cutaneous manifestations. Amyloidosis, POEMS syndrome, cutaneous plasmacytoma, xanthomas, benign hypergammaglobulinemic purpura of Waldenström, and scleromyxedema are emphasized.

Necrotic changes of the spinal cord with immune-complex-mediated disseminated vasculitis in a case of atypical allergic encephalomyelitis

A 42-year-old woman demonstrated recurrent, progressive neurological symptoms of peripheral and central nervous system damage of undefined infectious origin. Laboratory investigations showed abnormalities in the CSF and serum, suggesting subacute viral infection. Neuropathological examination revealed complete, widespread necrosis in the cervical and thoracic segments of the spinal cord with mononuclear and microglial infiltrations. There was pronounced thickening and fibrinoid necrosis of the vessel walls with mononuclear cuffs along the spinal cord. Dispersed, similar but less intensive inflammatory changes were present in the medulla oblongata, midbrain and basal ganglia. Surprisingly, there was diffuse demyelination with only slight glial and inflammatory reactions throughout the white matter of both hemispheres. The finding of coarse- and fine-grained deposits of IgG and C3 component of complement in the vessel walls of the spinal cord and vasa nervorum of cervical roots and peripheral spinal nerves, together with positive heterologous complement binding and the results of glycine-HC1 buffer elution, suggested immune-complex-mediated disseminated vasculomyelinopathy of the CNS and PNS. Consequent local ischemic changes and hypersensitivity phenomena led to frank necrosis of the cervical spinal cord and to extreme white matter demyelination in the brain. The case was diagnosed as allergic encephalomyelitis in which diffuse demyelination occurred coincidentally with spinal cord necrosis.

Two types of inflammatory vascular disease in Sjögren's syndrome. Differential association with seroreactivity to rheumatoid factor and antibodies to Ro (SS-A) and with hypocomplementemia

Two types of inflammatory vascular disease (IVD) occur in Sjögren's syndrome: neutrophilic IVD (NIVD) and mononuclear IVD (MIVD). In 45 patients with Sjögren's syndrome, we examined the 2 types of IVD with respect to serologic associations. NIVD, unlike MIVD, was significantly associated with seroreactivity reflected by hyperglobulinemia (P = 0.01), rheumatoid factor (P = 0.002), antinuclear antibodies (P = 0.02), and antibodies to Ro (SS-A) (P = 0.00006), and with hypocomplementemia (P = 0.03). The differential association of the 2 types of IVD with serologic reactivity and hypocomplementemia suggests that there may be basic differences in the immunopathogenesis of these 2 forms of IVD in Sjögren's syndrome.

Autoimmune disease in hairy-cell leukaemia: clinical syndromes and treatment

Thirty-seven patients with hairy-cell leukaemia were retrospectively reviewed for the presence of autoimmune disease. Ten definite and two probable cases were identified; these patients had positive serologies (immune complexes, antinuclear antibodies or rheumatoid factor) or biopsy-proven vasculitis. Clinically, two distinct syndromes were recognized. Six patients had joint symptoms, usually associated with nodular skin lesions; all responded promptly to therapy. Four additional cases had a more severe disease consisting of fevers, malaise, weight loss, skin rash, and variable visceral involvement; there was one death in this group. There appeared to be no relationship between presence of vasculitis and the severity or progression of the underlying malignant disease. We conclude that autoimmune disease is much more frequent in hairy-cell leukaemia than has previously been recognized, and that the outcome in these syndromes is usually good. Although the autoimmune syndrome generally responds promptly to splenectomy, corticosteroids, or cytotoxic therapy, failure to recognize this complication may lead to increased morbidity and occasional mortality.

Association between post-pericardiotomy syndrome and coronary occlusion after aortic valve replacement

Fever, leucocytosis, and pericardial and pleural effusions developed after the first postoperative week in a 56 year old man who had undergone aortic valve replacement. Four months later, coronary angiography showed bilateral proximal stenosis of the coronary arteries. In this patient post-pericardiotomy syndrome and subsequent coronary artery stenosis were thought to be associated and an immunological mechanism was suspected.

Segmental necrotizing glomerulonephritis: diagnostic, prognostic, and therapeutic significance

Renal biopsies from 50 patients with segmental necrotizing glomerulonephritis (SNGN) were divided into three groups on the basis of initial clinical information: (group A) Wegener's granulomatosis (WG)--14 patients; (group B) SNGN without renal vasculitis (RV)--21 patients; and (group C) SNGN with RV--15 patients. Renal biopsy findings did not distinguish the SNGN in WG from non-WG patients. However, focal endocapillary proliferation was more common in non-WG groups B (48%) and C (33%) than in WG (7%). In addition, GBM deposits of both IgG and C3 were present in 35% of biopsies in group B and 33% in group C in comparison to only 7% in WG. Glomerular fibrin deposition was common in all groups (54% group A, 70% group B, and 100% group C), suggesting that coagulation plays a role in the development of SNGN. Histologic parameters of severity and chronicity of the SNGN were inconsistent predictors of outcome, although an increased percentage of crescents in the non-WG groups correlated with a poorer prognosis. Chronic renal failure developed in 46% of group A patients, 65% group B, and 73% group C. After clinical follow-up, 15 patients had WG, 15 patients had documented or suspected systemic vasculitis (SV), and idiopathic SNGN was present in 20 patients. Sixty-six percent of patients with SV had RV, and 62% of biopsies with RV were from patients with SV. Chronic renal failure developed in 78% of patients with idiopathic SNGN and 57% patients with SV. These findings confirm that SNGN carries a poor prognosis, independent of its association with WG or SV. Fourteen of the 15 WG patients were treated with alkylating agents, and the development of chronic renal failure appeared to be related to delays in diagnosis and therapy. In the non-WG groups, presentation in acute renal failure with high serum creatinine and long duration of symptoms was predictive of development of chronic renal failure. Therapy in the non-WG patients consisted of alkylating agents (seven patients), steroids (20 patients), and dialysis only (seven patients). The seven non-WG patients treated with alkylating agents had clinical responses similar to WG patients, and cyclophosphamide therapy appeared to be most beneficial to patient outcome. Results of this retrospective study stress the importance of early diagnosis and, although based on small numbers of patients, suggest that aggressive chemotherapy should be recommended for SNGN, independent of its association with biopsy-proven WG or documented SV.

Ocular involvement in the respiratory vasculitides

The respiratory vasculitides are idiopathic inflammatory syndromes, characteristically involving the pulmonary vasculature as well as that of several other organ systems. The inflammatory response in these diseases is uniformly granulomatous. There are three distinct, recognized respiratory vasculitides: Wegener's granulomatosis, Churg-Strauss syndrome (allergic granulomatosis and angiitis), and lymphomatoid granulomatosis. Each of these entities may have ophthalmic manifestations, and ocular involvement may, in fact, be the presenting sign. The systemic and ocular manifestations, as well as the differential diagnosis and management of each of these entities are discussed.

The clinical spectrum of necrotizing angiopathy of the peripheral nervous system

The peripheral neuropathy seen with necrotizing angiopathy is said to begin classically as a mononeuritis multiplex, usually associated with polyarteritis nodosa, rheumatoid arthritis, or systemic lupus erythematosus. Our experience, however, suggests that a large number of these patients do not have a well-defined collagen vascular disease or the typical clinical pattern. In 350 consecutive nerve biopsies (sural or superficial radial), 16 patients showed a necrotizing angiopathy in the epineurial blood vessels. Six of these 16 patients had a distal symmetrical sensorimotor polyneuropathy. The remaining 10 had a mononeuritis multiplex, although in 8 overlapping nerve involvement somewhat obscured the picture of mononeuritis. In 12 patients, no specific underlying collagen vascular disease could be diagnosed by accepted criteria despite extensive clinical, radiological, and serological evaluations. The peripheral neuropathy was the only objective evidence of vasculitis in 7 of these 12 patients. Our findings suggest that patients with a peripheral neuropathy secondary to necrotizing angiopathy often do not have a definable collagen vascular disease. In fact, peripheral neuropathy may be the sole manifestation of vasculitis. Furthermore, the neuropathy was found to be a distal symmetrical sensorimotor neuropathy in a higher proportion of cases than has been documented previously.

Pathogenesis of cutaneous lupus erythematosus

Antibody-dependent mechanisms of tissue damage are the principle mechanism of disease in systemic and cutaneous lupus erythematosus. Antibody-dependent mechanisms of keratinocyte damage appear to be a primary pathogenetic factor in all forms of papulosquamous cutaneous lupus. Photosensitive papulosquamous lupus syndromes, such as subacute cutaneous LE, neonatal LE, "ANA-negative" LE, and complement-deficient LE are all strongly associated with antibodies to the ribonucleoprotein SSA. Evidence is accumulating that antibodies to SSA (and perhaps to SSB) induce antibody-dependent cell-mediated cytotoxicity (ADCC) of basal keratinocytes in all of these lupus syndromes. Evidence is also growing that autoantibodies in cutaneous LE syndromes are directly involved in disease pathogenesis, and are not simply markers of disease subsets. The relationship of the photosensitive anti-SSA-associated LE syndromes to more classical discoid LE or to acute papulosquamous LE in SLE patients remains to be studied. In both discoid LE and acute LE, basal keratinocyte damage can be seen, just as in the anti-SSA-associated photosensitive LE syndromes, but other antigen-antibody systems may be involved in initiating keratinocyte damage, or other cytotoxic mechanisms may produce keratinocyte damage characteristic of these syndromes.

Human hypersensitivity angiitis, an immune complex disease

Human hypersensitivity angiitis is an immune complex disease in which patients present with palpable purpuric lesions of the skin and may often have multiple organ involvement. The antigen may be derived from an infectious organism such as the hepatitis virus, streptococcus, or a drug, and complexes with antibody. Under circumstances of vascular turbulence or vessel wall dilatation this complex may become fixed, activating the complement sequence with elaboration of chemotactic factors for neutrophils. These cells release lysosomal enzymes resulting in vessel wall destruction. Red blood cells leak into the tissue producing purpura and the inflammatory infiltrate accounts for the palpability. Although many patients have skin lesions only, others may have involvement of joints, gastrointestinal tract, kidneys, and even the lungs. The central question in the pathogenesis of this disease is why the immune complex is so selective in its site of deposition. Part of the reason must be related to the lattice formation of a particular complex, while other reasons are related to host factors of altered vascular permeability, integrity of clearance mechanisms or even a genetically determined defect of the phagocytic system.

Takayasu's disease associated with generalised amyloidosis

A case of Takayasu's disease in a young Caucasian female is described. The major complications which developed over the ten year course of the disease include nephrotic syndrome, severe refractory hypertension, aortic valve regurgitation associated with aneurysmal dilatation of the ascending aorta, and recurrent congestive heart failure. Amyloid deposits have been demonstrated in the aorta, atrial appendage, aortic valve, and renal cortex. The association of amyloidosis and Takayasu's disease is discussed.

Rheumatoid vasculitis: experience with 13 patients and review of the literature

Rheumatoid vasculitis is an uncommon but potentially catastrophic complication of RA. There are few current extensive experiences and no consensus regarding the clinical, laboratory, histologic features, and management or prognosis of rheumatoid vasculitis. We therefore reviewed selected observations in 13 patients followed over the past decade and compared them with patients reported and with results of a survey of North American Rheumatologists. Our patients were seven men and six women (age, 33 to 70 years) who had had active RA for 4 to 36 years. They exhibited sensory neuropathy, mononeuritis multiplex, Felty syndrome, cutaneous lesions, leg ulcers, gangrene, anemia, leukocytosis, eosinophilia, high titers of RF, hypocomplementemia, and CICs or cryoglobulinemia approximately as frequently as other reported patients with rheumatoid vasculitis, but they displayed constitutional symptoms, subcutaneous nodules, ischemic changes, and proteinuria rather less consistently than in other series. These observations were not necessarily as expected by survey respondents. We, as in other series and suggested by survey respondents, tended to select penicillamine or cytotoxic drugs (or plasmapheresis) for patients with mononeuritis, gangrene, or leg ulcers, and nonsteroidal antiinflammatory drugs, antimalarials, gold, or penicillamine for sensory neuropathy or digital lesions. Four patients died, two deteriorated, and seven were stable or improved, a finding that was also similar to the experiences of others. Rheumatoid vasculitis is an uncommon, potentially catastrophic syndrome with varying clinico-pathologic features that have different prognostic implications and should be managed individually.

Cardiovascular manifestations of systemic lupus erythematosus: current perspective

Cardiovascular manifestations develop in the majority of SLE patients at some time during the course of their illness, the most common being acute fibrinous pericarditis and pericardial effusion. Echocardiography has demonstrated an increased incidence of pericardial effusion, even in those who have minimal symptoms. Chronic adhesive pericarditis, pericardial tamponade, and constrictive pericarditis occur rarely. While myocarditis is commonly noted at autopsy, it is often silent clinically. Diagnosis during life can be confirmed only by endomyocardial biopsy. Electrocardiographic changes are often nonspecific. Endocarditis with superimposed nonbacterial verrucous vegetations (Libman-Sacks) is noted in more than 40% of hearts at autopsy, but is rarely diagnosed during life. Valve dysfunctions, such as aortic stenosis, aortic insufficiency, mitral stenosis, and mitral insufficiency, occasionally manifest during life and rarely may necessitate surgery. Atrial and ventricular arrhythmias, first degree AV block, and acquired CHB occur in association with pericarditis, myocarditis, vasculitis, and myocardial fibrosis, respectively. CCHB developing in newborns of mothers with SLE, particularly those who have an antibody to soluble tissue ribonuclear protein RO(SS-A), is increasingly being appreciated by both pediatric cardiologists and rheumatologists. Recently, severe coronary atherosclerosis resulting in angina pectoris and/or myocardial infarction in young adults has been noted, particularly in those who had developed risk factors such as hypertension and hyperlipidemia while receiving prolonged corticosteroid therapy. Rarely, coronary arteritis may produce similar symptoms. Congestive heart failure of either single or multiple etiologies carries an ominous prognosis. It remains a cause of high morbidity and mortality unless recognized early and treated properly. Extracardiac vascular manifestations of SLE include telangiectasia, vasculitis, livedo reticularis, Raynaud's phenomena, and thrombophlebitis, all of which may occur either alone or in different combinations. Evidence is now slowly accumulating that substantiates that immune complex deposition, complement activation and subsequent inflammatory reaction is responsible for the majority of the cardiovascular manifestations of SLE, for example, pericarditis, myocarditis, endocarditis, coronary arteritis, coronary atherosclerosis, and systemic and pulmonary vasculitis.(ABSTRACT TRUNCATED AT 400 WORDS)

Cerebral amyloid angiopathy associated with giant cell arteritis: a case report

A case of cerebral amyloid angiopathy associated with granulomatous arteritis is presented with description of the microscopic, immunocytochemical and ultrastructural features. The amyloid proved to be of the AL-type, with failure to show reactivity with anti-AA, anti-prealbumin and anti-albumin. Antisera against SAP and IgG (AF) did show reactivity. Hence the immunologic characteristics of this amyloid differ from those of other known conditions and may therefore represent a new form of amyloid. The role of granulomatous arteritis in this case remains speculative.

Lymphomatoid granulomatosis. Light microscopic, electron microscopic and immunohistochemical study

A case of lymphomatoid granulomatosis (LYG) involving the lungs, skin, stomach, and possibly the left kidney in a 60-year-old man is presented. The infiltrates in the lungs, stomach, and skin showed a polymorphic appearance, and consisted predominantly of lymphocytes of mature and blastic form and of a few neutrophils, plasma cells, and histiocytes. Most lymphoid cells showed irregularly shaped nuclei and clustered dense bodies, characteristics indicative of T lymphocytes. An immunohistochemical study confirmed the T cell origin of the lymphocytes; i.e. they were positive for Leu-1, Leu-3a and Ia-like antigens but negative for Leu-2a antigen and the antibodies against light chains. The homogeneity of the major population of infiltrates in LYG indicates that at least some forms of LYG may be neoplastic or pre-neoplastic lymphocytic disorders which may ultimately progress to malignant lymphoma.

Pulmonary manifestations of the rheumatic diseases

The collagen vascular diseases represent a heterogeneous group of multisystem disorders with a wide range of clinicopathologic features. Although these diseases represent distinct clinical entities, a great deal of overlap exists between them. For example, the diffuse interstitial fibrosis of SLE, RA, DM-PM, PSS, and MCTD are indistinguishable clinically, radiographically, and histologically. Conversely, the pulmonary manifestations of the various vasculitides all differ significantly from each other in their clinicopathologic presentation, as well as in their response to therapy. For diagnostic purposes, histologic evidence will usually be required for the pulmonary manifestations of the rheumatic diseases. Therapy must then be individualized for each of these entities, as the protocol and response are variable.

Correlation of disease activity in systemic vasculitis with serum C-reactive protein measurement. A prospective study of thirty-eight patients

In a prospective study over 2 years, serum C-reactive protein (CRP) concentration and erythrocyte sedimentation rate were measured serially in thirty-eight patients with various types of necrotizing systemic vasculitis. The CRP concentration was always elevated in patients with active vasculitis and fell rapidly in association with clinical remission induced by immunosuppression. During periods of complete remission, in the absence of any intercurrent condition, the value remained within the normal range. In contrast the sedimentation rate responded more slowly to changes in disease activity and did not necessarily reflect the level of inflammation at a particular time. These results, together with the commercial availability of rapid and precise assays for CRP, indicate that serial measurement of the serum CRP fills the urgent need for an objective index of the activity of the systemic vasculitides and their response to therapy.

IgE-containing circulating immune complexes in Churg-Strauss vasculitis

In five patients with vasculitis, hypereosinophilia, and elevated serum IgE levels a diagnosis of Churg-Strauss syndrome was established. To identify a possible role of IgE in pathogenic mechanisms leading to the vasculitis, we performed a sequential precipitation of the patients' sera with different concentrations of polyethylene glycol (PEG) 6000. Using a radio immunosorbent test, we tested the precipitates obtained for IgE. Considerable amounts of IgE were traced in the serum precipitates of all patients, especially after the second precipitation step (4.0% PEG). In contrast, no IgE-containing precipitates were detectable in sera from patients with different allergic diseases and high IgE serum levels. Together with an increase in C3d serum levels and the failure to demonstrate C1q-binding material in patients' sera, these data suggest the involvement of IgE-containing immune complexes in the pathogenesis of Churg-Strauss vasculitis, activating the complement via the alternate pathway.

The ophthalmological findings in autosomal recessive severe juvenile arteriosclerosis

Severe juvenile arteriosclerosis (JAS) is a rare, fatal disease with probably autosomal recessive inheritance. Precocious arterial murmurs and calcification of aorta and major arteries are associated with anaemia, growth retardation, prolonged systolic hypertension, gradual renal failure, gastrointestinal perforations, and early death. The ophthalmological findings in 5 boys and 1 girl between 7 and 17 years of age were retinal vascular tortuosity of main vessels, pre-capillary arterioles and post-capillary venules, sausage-like bulging of central main arterioles and microaneurysms of arterioles of the central fundus. Narrowing and local constriction was a typical feature of peripheral arterioles. The combination of findings documented by fluorescein angiography in 4 children was typical for severe juvenile arteriosclerosis.

Autoantibodies against neutrophils and monocytes: tool for diagnosis and marker of disease activity in Wegener's granulomatosis

Immunoglobulin G (IgG) autoantibodies against extranuclear components of polymorphonuclear granulocytes were detected in 25 of 27 serum samples from patients with active Wegener's granulomatosis and in only 4 of 32 samples from patients without signs of disease activity. In a prospective study of 19 patients these antibodies proved to be better markers of disease activity than several other laboratory measurements used previously. The autoantibodies were disease specific and the titres were related to the results of an in-vitro granulocyte phagocytosis test, in which 7S IgG antibodies were internalised after specific binding to the cell, resulting in gradual formation of ring-like cytoplasmic structures. This autoantibody may have a pathogenetic role in Wegener's granulomatosis. The detection of this antibody is valuable for diagnosis and estimation of disease activity.

Polyneuropathy due to polyangiitis overlap syndrome

A patient presented with a mild polyneuropathy, developed a large intra-abdominal haemorrhage and died of cardiac arrest within a few days. Microscopic examination revealed a polyangiitis overlap syndrome (Fauci) with lesions in many organs, including the peripheral nerves and the heart. A myocarditis was considered to be the cause of death.

Livedo racemosa generalisata and stroke

The authors describe three young female patients with generalized livedo racemosa and cerebral infarction. The radiologic and biopsy findings point to a widespread vasculopathy, involving small and mid-sized arteries. The histologic examination of the temporal artery biopsy in two patients gives additional evidence for a chronic endarteritis as possible underlying cause of this disease entity.

Wegener's granulomatosis: observations on treatment with antimicrobial agents

Twelve patients with Wegener's granulomatosis were treated with antimicrobial agents, chiefly trimethoprim-sulfamethoxazole. The clinical course improved in 11 of the 12 patients who received this treatment. The success of antimicrobial treatment suggests the possibility of a microbial infection as the inciting cause of Wegener's granulomatosis in some patients. Alternatively, these agents--in particular, trimethoprim-sulfamethoxazole--may possess immunosuppressant activity.

Increased von Willebrand factor antigen in the plasma of patients with vasculitis

The plasma concentrations of von Willebrand factor antigen (vWF:Ag) were determined in 101 patients who had the following diagnoses: vasculitis 8 patients, systemic lupus erythematosus (SLE) 51, rheumatoid arthritis (RA) 28, asthma 7, hereditary angioedema 7. The greatest mean concentration of vWF:Ag, 469% (normal 100% +/- 50), was observed in patients with vasculitis, often without elevation of the erythrocyte sedimentation rate. The mean concentration of vWF:Ag was also increased in both SLE (277%) and RA (194%). Twenty-four patients (15 with SLE, 6 with vasculitis, 3 with RA) had vWF:Ag concentrations greater than 300%. Four of these patients died within 1 year of the date of the study. Of the 15 SLE patients, 9 had vasculitis and 2 had active glomerulonephritis. The 3 RA patients had severe disease associated with extraarticular manifestations. Elevated vWF:Ag may reflect vascular damage, while markedly elevated levels of vWF:Ag appear to indicate a poor prognosis.

Giant cell arteritis presenting with peripheral neuropathy

A 76-year-old woman with giant cell arteritis who presented with peripheral neuropathy is described.

Management of orbital inflammatory disease. A protocol

A step-by-step practical approach to orbital inflammatory disease is presented. In our hands, this proposed protocol has been useful. In any patient with orbital inflammatory disease, the ophthalmologist must initially rule out a life-threatening bacterial orbital cellulitis. Because the orbital disease presentation may be part of a systemic process, a good history and appropriate systemic work-up are mandatory. If any suspicion of bacterial orbital cellulitis exists, we recommend that intravenous antibiotics be instituted. Concurrently, orbital computerized tomographic scan may be extremely helpful in the work-up. Specifically, three findings--presence of an orbital-mass lesion without sinus involvement or bone erosion, presence of an orbital-mass lesion with sinus involvement or bone changes, or thickened extraocular muscles on CT scan--lead to the differential diagnosis, decision to biopsy, and appropriate treatment.

Small vessel vasculitis presenting as neurological disorder

Three patients with skin or muscle biopsy evidence of small vessel vasculitis presented with neurological symptoms: (1) frequent transient ischaemic attacks, (2) myalgia with encephalopathy, and (3) myalgia with marked weakness. The diagnosis of small vessel vasculitis needs consideration especially if presentation with polyneuropathy or cutaneous involvement is associated with elevation of ESR or serum immunoglobulins. Neurological illness may be a more common presentation of small vessel vasculitis than previously recognised.

[Systemic manifestations of angiitis with asthma and hypereosinophilia. Study of 10 cases]

We report 10 cases of systemic manifestations of angiitis with asthma and hypereosinophilia, some of which had the pathologic features of an allergic granulomatous angiitis of Churg and Strauss. We compare these 10 cases with 109 observations previously reported in the literature from which they differ by a high incidence of digestive tract involvement and by a near constant increase of total plasma immunoglobulin E concentration during the evolutive phases of vasculitis. Broncho-alveolar lavage had been performed in 3 patients, showing pulmonary hypereosinophilia. We discuss the clinical, biological and pathogenic features which differentiate this syndrome, particularly from periarteritis nodosa.

Painful lumbosacral plexopathy with elevated erythrocyte sedimentation rate: a treatable inflammatory syndrome

Six patients had a syndrome of painful lumbosacral plexopathy and elevated erythrocyte sedimentation rate. Sural nerve biopsy in each case showed axonal degeneration and epineurial arterioles surrounded by mononuclear inflammatory cells. Differential fascicular involvement suggested an ischemic cause in three nerves, but no patient had a necrotizing vasculitis. None of the six patients had vasculitis or cancer. Three of the six were diabetic and were initially thought to have diabetic plexopathy, but deterioration continued despite control of the diabetes. These six patients appeared to have an ischemic neuropathy with an immunological basis. Five were treated with immunosuppressant drugs, and in four the plexopathy improved or was arrested. The pathogenesis is unclear, but postmortem findings in one case suggest that the syndrome does not stem from an underlying vasculitis.