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

Objective monitoring of disease activity in polyarteritis by measurement of serum C reactive protein concentration

Serial measurements of the serum concentration of C reactive protein were made in 27 patients with polyarteritis over six years. The concentration was invariably raised when the disease was active, even in patients receiving immunosuppressive treatment, 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. The correlation between C reactive protein concentration and disease activity was much closer than that between erythrocyte sedimentation rate and disease activity. These results indicate that serial measurement of the serum C reactive protein concentration fills the urgent need for an objective index of the activity of polyarteritis and its response to treatment.

Recovery from rheumatoid cerebral vasculitis

A 48-year-old woman with the classical features of longstanding rheumatoid arthritis acutely developed a diffuse cerebral disease. Angiograms showed extensive cerebral vasculitis, and CT scan demonstrated cerebral oedema and haemorrhage. Her clinical state, EEG and CT scan rapidly returned to normal following treatment with corticosteroids.

Electron-dense deposits in the renal arterioles of two patients with hypersensitivity vasculitis

Immune complex deposition in the vessel wall is presumed to be the major pathogenetic mechanism leading to hypersensitivity vasculitis. Despite this, histologic evidence of vascular immune complex deposition such as that provided by electron-dense deposits has been reported only rarely in dermal vessels and never in visceral organs. The cases of two patients with hypersensitivity vasculitis affecting primarily the skin and the kidney are reported. Clinical renal involvement was manifested by proteinuria, hematuria, and a moderate increase in serum creatinine in one case. Renal biopsy showed minimal glomerular changes in one patient and focal necrotizing glomerulitis in the other. The arterioles appeared normal on light microscopic examination. However, obvious electron-dense deposits in the arteriolar wall could be demonstrated electron microscopically in both cases. This observation lends strong support to the theory of immune-complex-mediated vascular damage as the main pathophysiologic mechanism in vasculitis with visceral involvement.

Acute glomerulonephritis. A clinical overview

Acute glomerulonephritis is a syndrome characterized by the abrupt onset of hematuria often accompanied by proteinuria, hypertension, edema, and renal dysfunction. Acute glomerulonephritis can be subdivided into primary glomerular disease, postinfectious glomerulonephritis, and glomerulonephritis associated with systemic disease. With few exceptions, the underlying mechanism of acute glomerulonephritis is an immunologic one. To differentiate clinically the specific etiology of the glomerulonephritis, attention must be focused on the presence of signs or symptoms of systemic disease, changes in the environment of the patient, family history of renal disease, and recent history of infectious disease.

Henoch-Schönlein purpura--a surgical review

A review of the complications associated with Henoch-Schönlein purpura is presented with particular reference to those requiring surgical management. Gastrointestinal involvement occurred in 105 patients and was complicated by intussusception in three patients and by perforation in one. Laparotomy was undertaken in 10 patients. Involvement of the scrotum and testis occurred in 29 patients and suggested torsion of the testis on occasion. Renal involvement occurred in 45 patients and was associated with renal impairment in six. Recommendations for the management of surgical complications are discussed.

Presence of complement-fixing anti-endothelial cell antibodies in systemic lupus erythematosus

Vasculitis in systemic lupus erythematosus (SLE) is associated with the deposition of IgG and complement in blood vessel walls. However, it is not known whether immune injury to endothelial cells is a part of this process. Therefore, we used a solid phase radioimmunoassay to study the ability of IgG from normal human sera and sera from patients with SLE to bind to endothelial cells. In this assay, cultured human umbilical venous endothelial cells were sequentially incubated with normal or SLE sera, goat anti-human IgG, and 125I-labeled staphylococcal protein A (*SPA). After exposure to normal sera, 2.5 +/- 0.5% (mean +/- SD) of the added *SPA bound to the cells, whereas after exposure to SLE sera 13.8 +/- 7.6% of the added *SPA bound to these cells. This difference in binding was highly significant (P less than 0.001). Binding was partially reduced when SLE sera were preincubated with B-lymphocytes or monocytes, but not after exposure to erythrocytes, platelets, or T lymphocytes. Incubation of endothelial cells with the 7S fraction of SLE sera or with the F(ab')2 fragment of SLE-IgG resulted in the deposition of greater than 80% as much IgG as was deposited on endothelial cells by whole serum. However, since higher molecular weight fractions (greater than 7S) of SLE sera were also active, we tested the capacity of endothelial cells to bind IgG complexes. Endothelial cells bound heat-aggregated IgG (HA-IgG) in a saturable manner at one log concentration below the binding of normal monomeric IgG. Binding of HA-IgG to endothelial cells was markedly enhanced by preincubation with a serum source of complement. Both HA-IgG and SLE-IgG also bound to freshly obtained endothelial cells in suspension, as detected by automated fluorescence flow cytometry. Binding of SLE-IgG and HA-IgG to endothelium initiated complement activation, deposition of the third component of complement, and disruption of the monolayer. In addition, SLE-IgG and HA-IgG caused endothelial cells to secrete prostacyclin and caused the adherence of platelets, confirmed by scanning electron microscopy. These studies demonstrate that IgG anti-endothelial antibodies are present in the sera of patients with active SLE. These sera may also contain IgG complexes that are capable of binding to endothelial cells. The association of IgG and complement with endothelial cells may initiate vascular injury in SLE and other human disorders.

Intravenous cyclophosphamide plus methylprednisolone in treatment of systemic rheumatoid vasculitis

Systemic vasculitis in rheumatoid arthritis shows similarities to polyarteritis nodosa and may require equally aggressive therapy. Forty-five patients with systemic rheumatoid vasculitis were studied during treatment with either cyclophosphamide plus methylprednisolone given by intermittent bolus intravenous injection (21 patients) or a variety of other more conventional drug regimens (24 patients). In this open study, the intravenous treatment group had more severe initial disease, a higher incidence of neuropathy, and more frequent evidence of necrotizing arteritis on biopsy than the other treatment group. Despite this, intravenous cyclophosphamide plus methylprednisolone resulted in more frequent healing of vasculitic lesions including leg ulcers and neuropathy, a lower incidence of relapse, fewer serious complications, and a lower mortality than did other treatments. Toxic effects were similar in both study groups. Intravenous cyclophosphamide plus methylprednisolone is a useful early treatment for systemic rheumatoid vasculitis.

Unusual Takayasu's arteritis: case report

Takayasu's disease, a condition with unusual clinical symptoms and peculiar radiologic manifestations is described. The clinical and physiopathological implications are discussed together with a literary review.

Wegener's granulomatosis in childhood: cutaneous manifestations as the presenting signs

Wegener's granulomatosis (WG), characterized by a necrotizing granulomatous vasculitis, is a rare systemic disease particularly infrequent in children. We report an unusual case of WG in a 16-year-old male patient in whom the cutaneous manifestations were the presenting signs that preceded the upper respiratory symptoms by several months. In addition, the finding of a calcified pulmonary lesion has never been reported in association with WG. Accurate diagnosis of early skin lesions is important in view of the available effective therapy. Clinical and pathologic features of WG and treatment are reviewed.

Hereditary angioedema and coronary arteritis

A 30-year-old white male with hereditary angioedema developed substernal chest pain with multiple arterial stenoses at coronary angiography. Histopathologic studies of the fibromembranous thickening removed from the left coronary artery at the time of the revascularization procedure revealed an inflammatory lesion compatible with an arteritis. The significance of this association in the spectrum of immunologically-mediated disorders in hereditary angioedema is discussed.

Immune complex glomerulonephritis in hydralazine-induced SLE

Renal disease, a major feature of systemic lupus erythematosus (SLE), rarely occurs in drug-induced SLE. Immune complex glomerulonephritis has been demonstrated in a few cases of SLE following procainamide or anticonvulsant therapy but has not been documented in association with hydralazine-induced SLE despite the recognition of this syndrome 30 years ago. We report the clinical and renal pathologic findings in a patient with hydralazine-induced lupus nephritis and review the renal pathologic material in earlier reports of hydralazine-induced SLE.

Necrotizing vasculitis from radiographic contrast media

Two patients in whom cutaneous necrotizing vasculitis and nephritis developed 12 to 22 hours after the intravascular injection of radiocontrast media are presented. In one patient, the fortuitous observation was made of sparing of the skin from vasculitis in an area into which xylocaine and epinephrine had been injected 4 hours prior to administration of the radiocontrast material. The possible mechanisms by which these reactions may have taken place and the potential implications are discussed.

Oral presentation of polyarteritis nodosa

A case of polyarteritis nodosa in a woman with oral manifestations and digital gangrene is presented. Oral lesions in this connective tissue disorder are rare, and few cases have previously been reported.

Rheumatoid vasculitis: diagnostic and therapeutic decisions

Rheumatoid vasculitis is an uncommon but potentially catastrophic complication of RA. There are few extensive experiences recorded in the current literature and there is no consensus regarding the clinical features, laboratory findings, histologic pattern, prognosis, or appropriate management of this syndrome. We therefore surveyed 1,947 North American ARA members for their perceptions of rheumatoid vasculitis. Four hundred twenty-eight surveys were returned, of which 290 were suitable for analysis. The majority of respondents were within 10 years of fellowships and were evenly distributed among private practice, and part-time and full-time academic positions. The respondents saw 15-50 rheumatoid arthritis (RA) patients weekly and less than five RA vasculitis patients annually. The majority correctly diagnosed two actual and complex case histories from patients with and without autopsy-proven vasculitis. Respondents associated the following features most strongly with rheumatoid vasculitis - mononeuritis multiplex, digital gangrene, digital ischemic lesions, nailfold ischemic lesions, non-healing leg ulcers, palpable purpura, fingertip nodules, sensory neuropathy, scleromalacia perforans, high titer rheumatoid factor, positive visceral angiography, cryoglobulinemia, hypocomplementemia, circulating immune complexes, and histologic necrotizing vasculitis or vascular transmural neutrophilia. Digital lesions or sensory neuropathy alone were not viewed as portending an ominous prognosis by most respondents and would have been treated with nonsteroidal anti-inflammatory drugs, antimalarials, gold salts, or D-penicillamine. Other clinical manifestations considered as reflecting rheumatoid vasculitis (gangrene, mononeuritis multiplex, ulcers) were thought to worsen prognosis and would have been managed more often with corticosteroids, D-penicillamine, cytotoxic agents or plasmapheresis. Rheumatoid vasculitis is viewed as a heterogeneous group of syndromes with varying clinical and histopathologic features,which have different prognostic implications, and therefore should be managed differently. While these dta do not substitute for an extensive recorded series of patients, they provide useful information about community perceptions of an uncommon but difficult clinical problem. They identify the need for additional data to examine the validity of these attitudes.

Lymphocyte subsets and Langerhans cells/indeterminate cells in erythema multiforme

A peroxidase-antiperoxidase study using monoclonal antibodies directed against T and B lymphocytes and Langerhans cells/indeterminate cells (LC/IC) was undertaken in order to understand more clearly the changes observed in erythema multiforme. At the various stages of development, from normal skin to target lesions, the quantity of inflammatory cells differed, but in each case the number of T8+ (cytotoxic/suppressor) cells was greater than the number of T4+ (helper/inducer) cells in the epidermis, whereas the latter exceeded the former in the dermis. Concomitant with the initial epidermis changes, there was an increase in the number of T6+ (LC/IC) cells in the upper and lower epidermis. With slight to moderate basal unit destruction, the number of LC/IC in the upper epidermis exceeded those in the lower epidermis. With severe basal unit destruction, there was a loss of LC/IC in the lower epidermis as detected by T6 reactivity. In fully formed blisters, the LC/IC in the upper half of the epidermis were decreased in parallel with the degree of epidermal necrosis. The character of the lymphocytic inflammatory infiltrate and redistribution in LC/IC are similar to those findings described in allergic contact dermatitis. The clinical, histologic, and immunopathologic changes in erythema multiforme appear to be due in part to cellular immune mechanisms with the lymphocyte as the predominant effector cell, and our data suggest a possible role for LC/IC in this disorder.

Therapy for immunologic disease. New ways of using old drugs

Treatment of immunologically mediated diseases has been hampered by the lack of therapeutic agents capable of selectively altering distinct areas of the immune network. Unfortunately, most immunomodulating drugs with such capability are not selective in their suppressive effects, often causing untoward reactions such as infection. In an attempt to obviate these effects, new schemes of administering these agents so as to minimize adverse side effects and maximize benefits have been developed. Such regimens utilizing corticosteroids and certain cytotoxic drugs are proving effective. Progress will probably be limited to the devising of new protocols for existing pharmacologic agents until newer drugs are developed that can more precisely modify specific phases of the exaggerated immune reactivity characteristic of immunologically mediated diseases.

Chronic neuropathy associated with immune complexes of hepatitis B virus

In 7 patients, including one autopsied case, with neuropathy associated with hepatitis B virus infection, histologic examination of sural nerve biopsies revealed small vessel vasculitis in the vasa nervorum. In all cases, immunofluorescent deposits of hepatitis B surface antigen, immunoglobulin and C3 complement were detected in the vasa nervorum. That these deposits could represent immune complexes composed of hepatitis B virus was supported by the serologic demonstration of high serum-level of immune complexes and by the ultrastructural demonstration of electron-dense deposits around the endoneural capillary and in the endoneurium. The densities of large myelinated fibers were significantly lower than controls (P less than 0.01) in 6 of 7 cases. These results suggest that immune complexes composed of hepatitis B virus might play a significant role in the pathogenesis of endoneural and epineural vascular lesions, through which neuropathy may be induced in patients with hepatitis B virus infection.

Pulmonary angiitis and granulomatosis revisited

Re-examination of the pathologic and clinical features of the entities traditionally classified under the heading "pulmonary angiitis and granulomatosis" indicates that there is little advantage in retaining this artificial category and that these entities should be considered variants of diseases to which they are actually related. Wegener's granulomatosis and allergic angiitis and granulomatosis appear to be examples of true systemic vasculitides in which the lung is a predominant but not the only or even the most important site of involvement. Wegener's granulomatosis may manifest with involvement limited to lung, a form that has been called limited Wegener's; however, many or most such cases progress to classic disease involving kidney and often upper respiratory tract. Similarly, Wegener's granulomatosis may present with disease limited initially to the upper respiratory tract (a form of midline granuloma); this process may also spread to involve lung and kidney. It seems unlikely that limited Wegener's is truly a separate disease category. Evaluation of the pathologic and clinical features of necrotizing sarcoid granulomatosis indicate that it very much resembles ordinary sarcoid in most histologic features, in the nature of extrapulmonary involvement, and in its clinical course and that it probably corresponds to the clinical--radiographic entity of nodular sarcoid. Lymphomatoid granulomatosis appears to have little relationship to the other members of the angiitis and granulomatosis group; its behavior and histologic features are those of a lymphoproliferative disorder that in most cases is or becomes histiocytic lymphoma. Some cases of so-called benign lymphocytic angiitis also fall into this category; the remainder appear to represent a variety of completely unrelated pathologic processes. Last, bronchocentric granulomatosis is most commonly one of the histologic manifestations of allergic bronchopulmonary aspergillosis, although it is likely that other agents or processes produce the same histologic pattern. Although the presence of a common set of pathologic features makes the concept of angiitis and granulomatosis attractive from a morphologic point of view, there is minimal clinical similarity among them, and these diseases appear to be totally separate entities.

Serologic and immunopathologic findings in temporal arteritis

In 104 patients undergoing biopsies for temporal arteritis, lymphocyte characterization identified both T4 helper/inducer and T8 cytotoxic/suppressor lymphocytes in approximately equal numbers. B lymphocytes were absent. Deposition of IgM and IgG was observed in three of 16 positive biopsy specimens. Antinuclear antibodies were present in ten of 16 biopsy-proven cases of temporal arteritis compared with 19 of 55 in the control group with negative biopsy specimens. Anti-smooth-muscle, anti-DNA, and antimitochondrial antibodies were not useful in distinguishing between the two groups.

SSA (Ro)-antibodies in Wegener's granulomatosis

In 4 consecutive cases of Wegener's granulomatosis with glomerulonephritis, antibodies against the extractable nuclear antigen SSA (Ro) could be demonstrated with counterimmunoelectrophoresis. Antibodies were demonstrable on admission and paralleled disease activity while patients were under therapy. This potential serological marker may be of value for diagnosis and follow-up of patients with Wegener's granulomatosis.

Indolent Wegener's granulomatosis

Classical Wegener's granulomatosis is a relentlessly progressive and rapidly fatal disease. A pulmonary 'limited form' is associated with a much better prognosis. We report 3 cases of Wegener's granulomatosis which ran a prolonged indolent course despite major manifestations outside the lower respiratory tract and review the literature on survival.

Neurological complications of vasculitis

The vasculitides are a group of disorders that include the polyarteritis nodosa group of systemic necrotizing vasculitides, hypersensitivity vasculitis, Wegener's granulomatosis, lymphomatoid granulomatosis, giant cell arteritis, Behçet's disease, and isolated angiitis of the central nervous system. Classification is based on clinical, angiographic, and histological features. The frequency and distribution of neurological involvement vary with the underlying disorder and may provide the initial symptoms. Polyarteritis nodosa and Wegener's granulomatosis may affect both the central and peripheral nervous systems, whereas isolated angiitis of the central nervous system and Behçet's disease affect the central nervous system alone. Neurological dysfunction occurs in 80% of patients with polyarteritis nodosa and fewer than 10% of patients with hypersensitivity vasculitis. The mechanism of neurological dysfunction in the vasculitides is tissue ischemia. The clinical effects of ischemia vary, and symptoms may be transient or prolonged. Mononeuritis multiplex, polyneuropathy, and stroke are frequent complications, but encephalopathies, cranial neuropathies, and brachial plexopathies are seen as well. The occurrence of symptoms late in the course of a disease suggests ischemia resulting from healed, scarred vessels as well as from those that are acutely inflamed; this is the case in Takayasu's arteritis and possibly also in polyarteritis nodosa. Treatment is based on identifying and removing the sensitizing agent when possible. Wegener's granulomatosis requires therapy with cyclophosphamide; temporal arteritis, with corticosteroids. In other vasculitides a balance must be reached between the progression of the disease and the side effects of immunosuppression.

Necrotizing vasculitis within cutaneous lesions of mycosis fungoides

Mycosis fungoides is a T cell lymphoma with a predilection for cutaneous involvement. This paper describes the clinical manifestations and histopathologic features of a case of mycosis fungoides with necrotizing vasculitis localized to the lesions of cutaneous lymphoma. Elevated levels of circulating immune complexes were found in this patient. The large numbers of perivascular malignant helper T lymphocytes may have induced immunoglobulin synthesis, resulting in the formation of these complexes followed by deposition in vessel walls and subsequent necrotizing vasculitis. Possible alternative mechanisms include the presence of anti-T cell antibodies, or cytotoxic effector cells.

Pseudotumoral enterocolitis and massive eosinophilia

We report a seven year history of a 23 year old woman born in the Antilles, with pseudotumoral enterocolitis and massive eosinophilia. In 1973 she developed a haemorrhagic colitis with massive peripheral eosinophilia of up to 60000/mm3. Medical treatment, mainly corticosteroids, failed to control the disease. The patient temporarily improved after colectomy and remained in remission for two years. In 1978 the disease recurred in the rectum and small intestine with formation of tumour-like granulomata and massive infiltration by eosinophils, unresponsive to corticosteroids. Intestinal blood and protein loss continued until death seven years after onset. In spite of exhaustive investigation, no parasites, allergens, or other aetiological agents could be found. As only the gut was infiltrated, the hypereosinophilic syndrome could be excluded. The enterocolitis here described does not correspond to an eosinophilic gastroenteritis, nor to other known inflammatory bowel diseases and to our knowledge has not been reported previously.

Selective renal angiography in Wegener's granulomatosis

Two patients whose illnesses meet the criteria of Wegener's granulomatosis are presented. Selective renal angiography performed in both revealed multiple arterial aneurysms similar to those classically found in polyarteritis nodosa.

Vasculitis in primary vasculitides, granulomatoses, and connective tissue diseases

Problems with the classification and diagnosis of vasculitides are discussed. The evidence related to the pathogenetic importance of immune complexes in vasculitis, both in experimental models and human disease, is reviewed. The finding, by immunofluorescence, of immunoglobulins and complement components in vessel walls has provided indirect evidence of a role of immune complexes in certain forms of human vasculitis. However, specific antigens have been demonstrated in very few instances, notably in some patients with hepatitis B infection. In most forms of human vasculitis there is no information about causative factors. The widely held belief that therapeutic drugs cause an appreciable proportion of cases of human vasculitis appears unfounded.

Intracerebral hemorrhage and vasculitis related to ephedrine abuse

Intracerebral hemorrhage occurred in a 20-year-old man following self-administration of ephedrine. Changes seen on cerebral angiography were typical of vasculitis, and immune complex deposition was found in a skin biopsy. This combination has not previously been reported with ephedrine abuse although it is well known with amphetamine abuse.

Ocular complications of Wegener's granulomatosis

140 patients with biopsy-proven Wegener's granulomatosis were examined during a 16-year period at the Mayo Clinic. Forty patients had diverse and explosive ophthalmic involvement, including conjunctivitis, episcleritis, scleritis, corneal ulceration, uveitis, retinal vasculitis, optic neuropathy, orbital mass, orbital cellulitis, and obstruction of the nasolacrimal duct. The multiple ophthalmic and systemic complications in these 40 patients and the importance of establishing the pathologic diagnosis are discussed. Treatment with corticosteroids and immunosuppressive agents has dramatically improved the prognosis, although substantial mortality (four patients died of Wegener's granulomatosis) and ocular morbidity (three eyes were enucleated) are still associated with this disease.

Necrotizing vasculitis associated with diphenylhydantoin: two fatal cases

Two fatal cases of widespread necrotizing vasculitis associated with diphenylhydantoin (Dilantin) are presented. Toxic and allergic reactions associated with diphenylhydantoin therapy have been discussed and reviewed in numerous reports since the late 1930s. This vascular complication, however, has previously been reported only twice. In this report, the authors discuss similarities in their two cases and the peculiarities of this entity in the broad spectrum of necrotizing angiitides.

Isolated angiitis of the central nervous system. Prospective diagnostic and therapeutic experience

Isolated angiitis of the central nervous system is an uncommon clinicopathologic entity characterized by vasculitis restricted to the vessels of the central nervous system without other apparent systemic vasculitis. Experience with the diagnosis, treatment, and follow-up evaluation in four patients with this disease is presented. Early manifestations of disease include severe headaches, altered mental function, and focal neurologic deficits. The pattern of progression from headaches and altered mental status to multifocal neurologic deficits is particularly suggestive of the diagnosis of vasculitis of the central nervous system. Systemic symptoms such as fever, myalgia, arthralgia, and arthritis, which occur frequently in other vasculitic syndromes, are generally not present in patients with isolated angiitis of the central nervous system. No single laboratory study can firmly establish or completely exclude the diagnosis; consequently, tissue diagnosis with biopsy of the brain parenchyma and leptomeninges may be required. In two patients, recurrent disease developed despite treatment with corticosteroids alone. Sustained clinical remission was induced in all four patients with a regimen of daily cyclophosphamide and alternate-day prednisone therapy. Cyclophosphamide and alternate-day prednisone therapy are considered the treatment of choice in severe, progressive, or corticosteroid-resistant isolated angiitis of the central nervous system.