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

Encephalopathy in the course of Wegener vasculitis

A 44-year-old woman presenting first ear disease and then cranial nerve, lung and kidney lesions and ultimately central nervous system involvement was found on kidney biopsy to have Wegener granulomatosis (WG). It is unlikely that the vasculitic component of the illness was directly responsible for most of the neurological symptoms.

Ophthalmologic abnormalities in the hypereosinophilic syndrome

Twelve patients with hypereosinophilic syndrome were studied to determine the frequency and type of eye involvement in this systemic disease. Four patients (33%) had visual symptoms, including blurred vision in one or both eyes, and one patient had an episode of complete blindness following cardiac surgery. Five patients (42%) had eye involvement by direct examination, and ten (83%) in fluorescent retinal angiograms. The principal defects noted were occlusions of major retinal vessels, choroidal infarct, and patchy or delayed choroidal filling. As these defects all occurred in patients with other severe systemic complications of the hypereosinophilic syndrome, including cardiologic disease, it is suggested that these lesions were the result of thromboembolic disease and that these patients should receive long-term anticoagulation. It was concluded that eye involvement is a frequent and important feature of the hypereosinophilic syndrome.

Giant cell arteritis presenting as interstitial lung disease

A 58-year-old woman had a clinical history compatible with polymyalgia rheumatica but with an unexplained interstitial lung disease. Evaluation, including biopsy specimens of temporal artery, lung, and gastrocnemius muscle, was consistent with giant cell arteritis. This case identifies giant cell arteritis as a cause of interstitial lung disease.

Wegener's granulomatosis of the subglottis and the upper portion of the trachea

A relatively little-known complication of Wegener's granulomatosis is involvement of the subglottis and upper part of the trachea, which is illustrated in this report on 17 patients. Each of the patients had biopsy-proved Wegener's granulomatosis of the nose and paranasal sinuses. Some had concomitant involvement of the eye, kidney, lung and skin. Nine of the 17 patients required tracheotomy; 5 still require a tracheotomy tube, and 4 have had decannulation (1 had successful reconstructive surgery of the trachea). Medical treatment consisted of cyclophosphamide, with or without corticosteroids. All 17 are currently alive, the average follow-up having been 81 months. The otolaryngologist plays a key role in the detection and management of patients with Wegener's granulomatosis, particularly when the onset is a sudden progressive upper tracheal obstruction with airway symptoms that may overshadow the sometimes more subtle nasal manifestations.

Anti-retinal autoimmunity and circulating immune complexes in patients with retinal vasculitis

Sera from 44 patients with isolated retinal vasculitis (RV), 38 patients with retinal vasculitis accompanying systemic inflammatory diseases (RV + SID), and 33 patients with a similar range of systemic inflammatory diseases without eye involvement (SID alone) were assayed for circulating immune complexes (CIC) and for anti-retinal autoantibodies. CIC were present in 41% of patients with isolated RV and 55% of patients with RV + SID, whilst anti-retinal antibodies were present in about 70% of all patients with RV. 42% of those with SID alone had CIC and 30% of those with SID alone had retinal autoantibodies. Titres of anti-retinal antibodies were higher in patients with RV than in those with SID alone. In isolated RV there was an inverse relation between pronounced retinal autoimmunity and the occurrence of CIC--i.e., the more severe autoimmune retinal disease occurred in CIC-negative patients. Most patients with RV + SID tended to have mild or moderate retinal disease accompanied by both retinal autoantibodies and CIC, but severe retinal disease occurred in CIC-positive patients who did not have circulating anti-retinal antibodies. Patients with SID alone had high titres of retinal antibodies only when they were CIC-positive. It is suggested that the formation of CIC, possibly of an idiotype/anti-idiotype nature, may be a compensatory mechanism accompanying anti-retinal autoimmunity and that an imbalance between autoimmunity and immune complex formation may be an important predisposing factor in the development of retinal inflammatory disease.

Polymyalgia rheumatica with diffuse cerebral disease responding rapidly to steroid therapy

A 58-year-old woman presented with the classical features of polymyalgia rheumatica. She also had a global dementia; CT scan and EEG showed diffuse cerebral disease. After steroid treatment, the polymyalgia rheumatica and dementia rapidly resolved and the CT scan and EEG became normal. The inter-relationships of the giant cell arteritides are discussed in the light of this report of the association of polymyalgia rheumatica and steroid-responsive diffuse cerebral disease.

Multiple interferons in the circulation of patients with systemic lupus erythematosus and vasculitis

Recently, we found interferon in the sera of patients with systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and Sjögren's syndrome. In this study, we surveyed a variety of other immunologically mediated diseases. We did not find interferon in the sera of patients with Wegener's granulomatosis, sarcoidosis, infectious mononucleosis, minimal change nephritis, kidney transplants, myasthenia gravis, or uveitis, but we did find this protein in the sera of patients with active systemic and cutaneous vasculitis. Attempts to characterize the interferon in the sera of patients with systemic lupus erythematosus and vasculitis revealed that antibody to alpha (leukocyte) interferon, but not to beta (fibroblast) interferon, partially or completely neutralized the antiviral activity. The failure of antibody to alpha interferon to completely neutralize the antiviral activity in certain specimens and the lability of the antiviral activity in some specimens to pH 2.0 treatment both suggest that more than one type of interferon was present.

Clearance mediated by splenic macrophage membrane receptors for immune complexes in cutaneous vasculitis

This study concerns 11 patients with immune complex associated cutaneous vasculitis (5 leukocytoclastic vasculitis or Gougerot Ruiter's disease, 3 essential mixed cryoglobulinaemia, 2 Henoch-Schönlein purpura and 1 Waldenström's hypergammaglobulinaemic purpura). By determining the clearance of 51Cr-labeled IgG sensitized erythrocytes we showed a slight modification in the splenic mononuclear phagocyte system. In patients with Gougerot-Ruiter's disease the clearance of the autologous IgG-coated erythrocytes was delayed in 1 patient, and normal in 2 patients. In contact, the 8 other patients showed accelerated rates of IgG-mediated clearance. There was no statistically significant correlation between clearance rate, serum complement component levels and composition and/or levels of circulating immune complexes. Thus, the accelerated clearance rate suggests an enhanced activity of the mononuclear phagocyte system IgG-Fc receptors.

Pulmonary immune complex deposition in Wegener's granulomatosis

Two male patients with pulmonary manifestations of Wegener's granulomatosis are presented. One had an elevated rheumatoid factor, and both had elevated levels of immunoglobulin E. Both demonstrated characteristic necrotizing granulomatous lesions on light microscopy of lung tissue. Immunohistologic analysis of lung tissue demonstrated a granular deposition of immunoglobulin G and complement. Raji cell assay of sera demonstrated elevated levels of circulating immune complexes in the sera of the one patient tested prior to any therapy. These findings support the hypothesis that immune complex deposition contributes to the pathogenesis of Wegener's granulomatosis.

Livedo reticularis and cerebro-vascular disease

Three cases are described in which extensive livedo reticularis was associated with premature cerebrovascular disease. The patients presented with transient cerebral ischaemic attacks and gradually developed permanent neurological damage with intellectual impairment. The value of detailed neuropsychological testing to identify bilateral cortical abnormalities is demonstrated. CAT scanning may reveal multifocal cerebral infarction. The nature of this condition is not understood.

Ischemic heart disease in systemic lupus erythematosus in the young patient: report of six cases

To clarify the clinical spectrum of coronary arterial abnormalities in systemic lupus erythematosus, the data were reviewed on six patients who had a diagnosis of lupus at ages 15 to 29 years and who had ischemic heart disease before age 35. Two patients had coronary arteritis diagnosed on postmortem examination. In a third patient alterations in coronary arterial anatomy occurred with angiographic improvement temporally related to the initiation of steroid therapy. The other three patients had severe diffuse atherosclerotic coronary disease that was identified in two at postmortem examination. In the third patient the course of the disease strongly suggested coronary atherosclerosis, and eventually coronary bypass grafting was performed for relief of angina. In summary, clinically important extramural coronary arteritis and atherosclerosis both occur, although rarely, in young patients with lupus. Coronary artery disease may occur with or without coexisting active extracardiac lupus manifestations. Short-term steroid therapy and follow-up angiography for those with angina and in whom coronary arteritis is suspected warrant consideration. When stable coronary arterial anatomy is demonstrated on follow-up angiography, management is determined by the patient's symptoms irrespective of the prior history of lupus and, if indicated, cardiac surgery for symptomatic relief can be safely performed.

Lymphomatoid Granulomatosis. Prospective clinical and therapeutic experience over 10 years

Fifteen patients with lymphomatoid granulomatosis were studied prospectively over a 10-year period. Thirteen of the patients received the therapeutic protocol of cyclophosphamide (2 mg per kilogram of body weight per day) and prednisone (1 mg per kilogram on alternate days). Previous reports had indicated that mortality from lymphomatoid granulomatosis was as high as 90 per cent. Of the 13 patients who received the cyclophosphamide and prednisone protocol, seven had complete remissions lasting for 5.2 +/- 0.6 years (mean +/- S.E.M.) Six of the seven with disease in remission have received no therapy for 28.3 +/- 5.7 months. Malignant lymphomas developed in seven of the eight who died, and only two of the eight had therapy for an adequate period. Since virtually all patients who did not have complete remission went on to have malignant lymphoma, early recognition and prompt treatment during the lymphomatoid-granulomatosis phase of disease may not only lead to complete remissions but also percent the development of a lymphoid neoplasm.

Fenoprofen nephropathy: lipoid nephrosis and interstitial nephritis. A possible T-lymphocyte disorder

Five patients are presented, each of whom had an acute idiosyncratic reaction to fenoprofen calcium (Nalfon) characterized by acute renal failure and marked proteinuria. Renal pathology was similar in all patients. Light microscopy revealed marked lymphocytic inflammatory infiltrates and normal glomeruli. Immunofluorescent staining was minimal or absent. Electron microscopy showed fusion of podocytes in otherwise normal glomeruli. Two patients were studied using T-cell and B-cell specific fluorescent staining, which revealed that the interstitial infiltrates were composed exclusively of T-lymphocytes. This finding is considered in relation to prior experimental and theoretic work. It is suggested that the various clinical and pathologic findings in fenoprofen nephropathy are all manifestations of a disordered cell-mediated immunity.

Leukocyte counts and cerebrovascular disease

Elevated total leukocyte count in a biennial examination period is shown to be a significant (p = 0.001) predictor of cerebral infarction (CI) incidence in the subsequent 2 yr examination period, in a large Japanese cohort study. This association is not explainable on the basis of corresponding age, sex or blood pressure levels. The extent to which the association might be attributable to cigarette smoking habits could not be thoroughly examined with available data. Relative risks associated with a specific elevated leukocyte count may be larger among persons less than 65 yr of age than among older persons. When counts of specific leukocyte cell lines are considered a significant (p = 0.0006) role for neutrophil count emerges, while an additional predictive role for other leukocyte cell types could not be detected. In contrast, there is a suggestion that cerebral hemorrhage (CH) risk may be lower following an elevated leukocyte count. In particular, a negative association between lymphocyte count and CH incidence in the subsequent biennial examination cycle, is nearly significant (p = 0.07), in spite of a rather small number of CH cases in the sample.

Immunology of adverse drug reactions

Adverse reactions to drugs often include an immunologic response. An understanding of immunologic mechanisms is useful in understanding the clinical manifestations of drug allergy. Predisposing factors to the development of allergic reactions to drugs include host factors as well as drug factors. Immune response relates to what we know about the components of the immune system as well as their differentiation and maturation processes. Immunologic reactions are often classified as Type I, Type II, Type III or Type IV, and these reaction types often correlate with clinical manifestations. For each reaction type the mechanism, drugs implicated, clinical manifestations, and treatment can be described.

Immunological disorders and auditory lesions

The mechanisms by which auto-immune diseases may result in hearing disorders are reviewed. This is followed by a more detailed consideration of specific autoimmune disorders generally associated with auditory dysfunction. Four pilot studies examining the relationship between auto-immune disorders and hearing loss are briefly presented.

Pathology of a new toxic syndrome caused by ingestion of adulterated oil in Spain

The Toxic Syndrome (TS) caused by ingestion of adulterated rapeseed oil in Spain is a new disease of multisystemic character whose aetiology and pathogenesis remains unknown. The most prominent pathological feature is a peculiar non-necrotizing vasculitis, that affects mainly the intima and involves vessels of every type and size in practically every organ. The TS begins with an acute clinical picture with pleuropneumopathy, fever, headaches, exanthems and eosinophilia. In these early clinical phases the main pathological findings were observed in the lungs and consisted of intense pulmonary interstitial oedema with scanty inflammatory mononuclear infiltrates. Ultrastructural study revealed hydropic degeneration of pneumocytes types I and II with desquamation of type I. The patients in this phase died of respiratory failure, later deaths were due to thromboembolic complications. Later still the patients developed a neuromuscular syndrome, sclerodermiform skin lesions and severe weight loss and died predominantly of infectious complications and respiratory failure. The anatomopathological picture in the peripheral nerves was that of inflammatory neuropathy with a lymphocytic perineuritis that led to perineural fibrosis with secondary axonal degeneration. The muscle presented an interstitial inflammatory myopathy at first followed by a neurogenic muscular atrophy. The skin lesions in the late phases consisted in dermal or dermal and subdermal fibrosclerosis, with vasculitis of the small arteries in the lower dermis. The salivary glands and pancreas showed vasculitis and interstitial inflammation which progressed to interstitial fibrosis and parenchymal atrophy.

Wegener's granulomatosis exhibiting the clinical features of Goodpasture's syndrome

A case is reported here, the clinical features of which raised the suspicion of Goodpasture's syndrome which was, however, at variance with the absence of antiglomerular basement membrane antibodies. Renal failure improved on immunosuppressive treatment and peritoneal dialysis, but the patient died of gastric haemorrhage from a peptic ulcer related to steroid treatment. Necropsy and microscopic study revealed abnormalities of liver and spleen, consistent with Wegener's granulomatosis. Immunohistologic studies of the kidney confirmed the presence of granular-type IgG deposits in the glomeruli. There were extensive fibrin deposits in the kidney. The ways and means for the differentiation of Wegener's granulomatosis from Goodpasture's syndrome, the potential pathogenetic role of immunocomplexes and fibrin deposits, and the therapeutic possibilities are discussed.

Cutaneous clinicopathologic correlation of allergic granulomatosis

Allergic granulomatosis is a distinct clinical syndrome occurring in adults with asthma, eosinophilia, and multisystem vasculitis. Atopy and drug sensitivity are other important features. The skin reactions are most commonly nodular and inflammatory lesions. A unique feature is the deep papulonodules, which may occur singly on the scalp or symmetrically on the extremities. Cutaneous findings may range from purpura to urticaria and ulceration. The most common histologic finding is the extravascular granuloma; however, necrotizing vasculitis of small vessels is seen, as well as periarteritis nodosa involving larger vessels of the skin. This varied histologic and clinical spectrum seen in patients with systemic allergic granulomatosis is a reflection of a unique host response to multiple antigens. The cutaneous findings imply that allergic granulomatosis probably represents a unique host response to the same causative and pathogenetic factors as are usually found in periarteritis nodosa and necrotizing vasculitis.

Giant cell arteritis limited to large elastic pulmonary arteries

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Case report: livedo reticularis in endocarditis

The peripheral manifestations of bacterial endocarditis are manifold and provide diagnostic clues as to the onset, etiology and potential complications of the disease. Petechiae, splinter hemorrhages, and Osler's nodes are among the more common cutaneous signs of endocarditis thought to be secondary to an allergic vasculitis or, as in the case of Osler's nodes, peripheral emboli. An asymmetric livedo reticularis rash was the initial presentation in a patient we recently treated with peptostreptococcus intermedius endocarditis, a heretofore undescribed dermal sign of endocarditis. Immunofluorescence studies of skin biopsies suggest that a livedo reticular rash may be one of the immune complex vasculitic syndromes associated with endocarditis.

Rheumatoid vasculitis

Today, we cannot conclude comments on the treatment of immune-complex disease without paying our respects to therapeutic plasmapheresis and leukapheresis. Numerous centers are beginning to examine the value of removing either plasma or lymphocytes from patients with many rheumatic diseases. Efficacy appears to be established in hyperviscosity diseases (Waldenstrom's), myasthenia gravis, Goodpasture's syndrome, RH sensitized pregnant mothers, and thrombotic thrombocytopenic purpura. In active rheumatoid arthritis, it is a useful short-term tool but hardly cost effective. Although it would appear to be an advance from the medieval concept of purging out the "evil humors," pheresis for rheumatoid vasculitis must be considered a limited research tool, which may teach us something about mechanism of action. The mechanical removal of immune complexes by pheresis probably requires additional remittive or immunosuppressive therapy to prevent rebound in immune complex production. Effort now need to be directed to the agents that initiate production of immune complexes. Once the host's antibody system is so stimulated, we often find ourselves trying to close the barn door after the horse is long gone.

Eosinophilic granulocytes and skin disorders

The eosinophilic granulocytes remain intriguing cells. At the moment there are several skin disorders such as incontinentia pigmenti (Siemens-Bloch), pustulosis of the newborn, etc, in which the presence of eosinophils has not yet been studied. Basic aspects of the function of the eosinophils and their relationship with other inflammatory cells are being eliminated gradually. In the near future it will become clearer why, in certain circumstances, eosinophils are necessary or undesirable. These new data will be of great significance for clinical dermatology and skin pathology. In what circumstances do the eosinophils modulate inflammatory reactions and when do the cytotoxic capacities come to the fore? Other chemotactic factors will be detected, especially those related to the local inflammatory cells, lymphocytes, macrophages, and polymorphonuclear leukocytes. With the aid of these findings it will be possible to understand better why eosinophilic granulocytes are present in different skin disorders. Finally, regulation and influence of their behavior may become a possibility.

Neurologic manifestations of systemic vasculitis. A retrospective and prospective study of the clinicopathologic features and responses to therapy in 25 patients

A combined retrospective and prospective study of a patient population with either or both biopsy and angiographic evidence of systemic necrotizing vasculitis was undertaken in order to delineate the neurologic manifestations of this syndrome. The type, extent and natural history of the lesions in the peripheral and central nervous system were evaluated, together with the response fo the nervous system disease to corticosteroids or cytotoxic agents or both. In 60 percent of the patients, there was involvement of the peripheral nervous system. Four patterns of neuropathy were seen: mononeuritis multiplex, extensive mononeuritis, cutaneous neuropathy and polyneuropathy. The central nervous system was involved in 40 percent of the patients, manifested predominantly by diffuse and focal disturbances of cerebral, cerebellar and brain stem function. This study demonstrates the complexity and heterogeneity of the neurologic complications of the systemic necrotizing vasculitides. With treatment of the vasculitic process and prevention of further insult, both the peripheral and central nervous system make significant, and at times, dramatic, recovery.