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

Sural nerve biopsy in systemic necrotizing vasculitis

This study of 17 patients with vasculitic neuropathy (polyarteritis nodosa in 11, rheumatoid arthritis in five, and systemic lupus erythematosus in one) revealed the following: (1) Polyneuropathy is the most common manifestation of peripheral neuropathy in polyarteritis nodosa. (2) Peripheral neuropathy is more common in systemic necrotizing vasculitis than physical evaluation alone suggests. Adequate electrophysiologic tests can detect asymptomatic peripheral neuropathy in a substantial number of patients. (3) Abnormal sural nerve condition is a prerequisite to the demonstration of vasculitis on biopsy of this nerve. Thus, in using abnormal sural nerve conduction as a guide in nerve biopsy, the diagnostic yield of sural nerve biopsy will be greatly enhanced.

Neurological complications of connective tissue and other "collagen-vascular" diseases

A variety of neurological complications may occur in the various connective tissue and "collagen-vascular" diseases. Most of these complications are due to vasculitis affecting various sites in the central or peripheral nervous system. While the evidence for definitive vasculitis in SLE is not strong, small vessel damage usually is present in anatomic sites which correlate well with clinical features. Although patients with rheumatoid arthritis also may have vasculitis, neurological complications are usually related to nerve compression by rheumatoid nodules or the arthritic process itself. Considerable controversy exists regarding the accuracy of various diagnostic tests. While corticosteroids are the mainstay of therapy for these conditions, there are no definitive studies proving their efficacy.

Primary fibromyalgia (fibrositis): clinical study of 50 patients with matched normal controls

Detailed clinical study of 50 patients with primary fibromyalgia and 50 normal matched controls has shown a characteristic syndrome. Primary fibromyalgia patients are usually females, aged 25-40 yr, who complain of diffuse musculoskeletal aches, pains or stiffness associated with tiredness, anxiety, poor sleep, headaches, irritable bowel syndrome, subjective swelling in the articular and periarticular areas and numbness. Physical examination is characterized by presence of multiple tender points at specific sites and absence of joint swelling. Symptoms are influenced by weather and activities, as well as by time of day(worse in the morning and the evening). In contrast, symptoms of psychogenic rheumatism patients have little fluctuation, if any, and are modulated by emotional rather than physical factors. In psychogenic rheumatism, there is diffuse tenderness rather than tender points at specific sites. Laboratory tests and roentgenologic findings in primary fibromyalgia are normal or negative. Primary fibromyalgia should be suspected by the presence of its own characteristic features, and not diagnosed just by the absence of other recognizable conditions. This study has also shown that primary fibromyalgia is a poorly recognized condition. Patients were usually seen by many physicians who failed to provide a definite diagnosis despite frequent unnecessary investigations. A guideline for diagnosis of primary fibromyalgia, based upon our observations, is suggested. Management is usually gratifying in these frustrated patients. The most important aspects are a definite diagnosis, explanation of the various possible mechanisms responsible for the symptoms, and reassurance regarding the benign nature of this condition. A combination of reassurance, nonsteroidal antiinflammatory drugs, good sleep, local tender point injections, and various modes of physical therapy is successful in most cases.

Lymphomatoid granulomatosis with multiple intracranial lesions. Care report

✓ A case of lymphomatoid granulomatosis with multiple intracranial lesions is reported. Important aspects of this vasculitis are discussed, including its propensity for lymphomatous transformation, its similarity to Wegener's granulomatosis, its predilection for certain sites, and its resistance to treatment. A correlation is described between the computerized tomography scan and the autopsy findings.

Polyarteritis nodosa, hairy cell leukemia and splenosis

Appendiceal vasculitis and splenosis in a young women provided pathologic evidence that a systemic necrotizing vasculitis preceded the onset of hairy cell leukemia by at least six years. As in other patients who have had both diseases, florid polyarteritis nodosa developed during the course of the malignancy. However, the antecedent vasculitis, as well as the coincidence of these rare diseases, indicate that systemic vasculitis does not necessarily result from hairy cell leukemia as previously reported and suggest that the two diseases might share a common pathogenesis or predisposing factor.

Prostaglandin E1 infusions for vascular insufficiency in progressive systemic sclerosis

Twelve patients with systemic sclerosis (SS) and severe Raynaud's phenomenon received infusions of prostaglandin E1 (PGE1) at a dose of 6-10 ng/kg/min, with either saline or 5% dextrose, for 72 hours in a single-blind cross-over study. The infusions were administered intravenously by centrally positioned catheters. Infusions were well tolerated with only mild side effects. Following the PGE1 infusion cold tolerance improved and attacks of Raynaud's phenomenon were less frequent, less severe, and shorter in duration. This subjective improvement was maintained for several weeks in most patients, and 2 noted healing of ischaemic ulcers. There was no significant change in objective measurements of hand function after either infusion. However, pain measured on a 10 cm visual analogue scale improved 2.19 cm with PGE1 and only 0.91 cm with normal saline (P less than 0.05). Temperature of the fingers and hands recorded by thermography did not change significantly with saline infusions, but did rise during PGE1 infusions (mean rise 2.0 degrees C at 48 hours, p less than 0.001), and was maintained when measured again 2 weeks later (mean rise 1.56 degrees C, p less 0.001). PGE1 may therefore be suitable treatment for Raynaud's phenomenon and the vascular insufficiency of systemic sclerosis and other connective tissue diseases.

Subungueal-splinter hemorrhage an early sign of thromboangiitis obliterans

Subungueal splinter hemorrhage (S.U.S.H.) has been reported in various conditions and may herald a serious systemic disease. It has been related to miscellaneous conditions such as: subacute bacterial endocarditis, severe rheumatoid arthritis, uninfected mitral stenosis, trichinosis, peptic ulcer, hypertension, neoplasm, trauma, and in some cases, is considered idiopathic. Some dermatologic conditions such as psoriasis, dermatitis, and fungal infections may also produce S.U.S.H. It consists of "a homogeneous mass of blood in a layer of squamous cells, adherent to the under surface of the nail, considered to be of embolic origin." In a brief review of pertinent medical literature on thromboangiitis obliterans, we were unable to find a description of its occurrence in this disease. The earliest lesions described in this condition are "painful vesicles on the pulp of digits with intense hyperemia and hypersensitivity of the surrounding skin." It is our opinion that S.U.S.H. is an earlier and quite useful sign of arterial involvement as seen in the following cases observed in our vascular disease section.

Retinal vasculitis in rheumatoid arthritis

A woman with exacerbation of severe rheumatoid arthritis developed lesions compatible with retinal vasculitis. Laboratory studies confirmed the diagnosis, and the rapid clinical improvement that accompanied a fall in circulating immune complexes suggested that the vasculitis was a direct consequence of the rheumatoid disease. From these observations retinal vasculitis should probably be sought in any patient with rheumatoid disease and the vasculitis added to the list of ocular complications of rheumatoid arthritis.

Polyarteritis nodosa as a cause of sudden deafness. A human temporal bone study

Pathological changes in the temporal bone are described in a case of polyarteritis nodosa in a 48 year old man in whom the onset of sudden unilateral deafness and vertigo occurred seven months prior to death as one of the early manifestations of the disease. The patient had received only a seven week course of prednisolone and, earlier, a two week course of anti-inflammatory agents. Autopsy revealed involvement of the arteries supplying the kidneys, testes, and pancreas. Changes within the temporal bone were seen bilaterally and there was thickening of the mucosa of the middle ear. Inner ear involvement was mainly limited to the cochlea, the deaf ear showing more pronounced changes. These changes included loss of the organ of Corti in the hook portion of the basal coil, absence of the tectorial membrane, and atrophy of the stria vascularis. The scala tympani was obliterated by fibrosis and new bone formation. The scala media showed hydrops, and a marked decrease in the spiral ganglion cells and nerve fibers supplying this portion of the cochlea was evident. Focal changes were seen throughout the remainder of the cochlea. The vestibular structures showed no detectable pathologic changes. Small vessel arteritis was found in the dural and subacuate vessels in both temporal bones.

Infantile periarteritis nodosa. Case report and review of the literature

The clinical and autopsy findings of a three-month-old male infant with infantile periarteritis nodosa are described adn the literature reviewed. Different stages of the inflammatory vascular process could be seen in the iliacal, axillary, carotidal, coronary and the small periadrenal-tissue-arteries. Secondary changes were found in the axillary and coronary arteries consisting of aneurysmal dilatation and thrombosis. Fatal myocardial infarction occurred thirty-nine days following hospital admission.

The protracted superficial phenomenon in pathergic (Wegener's) granulomatosis

Twelve cases of pathergic (Wegener's) granulomatosis are described, with special attention focused on the long duration of mucosal and skin lesions in untreated cases, designated as the protracted superficial phenomenon, and on the histologic features that may be helpful in making the diagnosis. The long duration, often the result of a lack of proper interpretation of histologic details, was associated in some of the cases studied with the development of intractable renal failure or mutilation of the face. Since cytotoxic therapy offers the opportunity to prevent these complications, the desirability of an early diagnosis is obvious. Biopsy is the principal means of diagnosis, and therefore interpretation of histologic details is of paramount importance. Helpful histologic features found in the extravascular and vascular tissues of the specimens studed were focal necrosis, fibrinoid degeneration, palisading granulomas, giant cells, and vasculitis. Nonpalisading foci of granular necrosis or fibrinoid degeneration appeared to precede the development of the typical palisading granuloma. Both focal necrosis and focal fibrinoid degeneration occurred independently of intrinsic vascular involvement and in themselves are distinctive features of pathergic (Wegener's) granulomatosis. There was predominance of the extravascular components in the cases studied with occasional absence of vasculitis. Both the extravascular and vascular components are important in making a definitive diagnosis, but the extravascular component is characteristic, even in the absence of vasculitis. The extravascular tissues and the vessels are parallel contemporaneous target tissues.

Hallucinogenic drug induced vasculitis

A case of malignant hypertension in a 20-year-old man who self-administered various hallucinogenic drugs is described. Renal angiography showed arteritic changes with aneurysms in renal vessels and focal renal cortical infarction. A dramatic response in terms of resolution of arteritis occurred with prednisone therapy. The impressive use of minoxidil and labetalol in the initial control of the hypertension is also demonstrated.

Circulating IgA-immune complexes in Henoch-Schönlein purpura. A longitudinal study of their relationship to disease activity and vascular deposition of IgA

In Henoch-Schönlein purpura immune complexes in inflamed vessel walls characteristically contain immunoglobulin A(IgA). To determine whether IgA is also the predominant immunoglobulin in circulating immune complexes, we compared the results of three immune complex assays with specificities for different classes of immunoglobulins in a longitudinal study of 37 patients (30 children and seven adults) with Henoch-Schönlein purpura. Circulating IgA-containing immune complexes were detected by their reactivity with a low avidity anti-IgA antibody in 27 of the 37 patients. IgA was simultaneously present in cutaneous vessel walls in 95 percent of the patients with circulating IgA-containing immune complexes. High levels of IgA-containing immune complexes were found only during the initial phase of the disease. Immune complexes containing bound complement breakdown products were demonstrated by binding to conglutinin. IgA was found in these immune complexes in 17 patients, IgG in 17 and IgM in nine patients. There was no apparent relation with the class of immunoglobulin in the deposits. Conglutinin-binding immune complexes were present later in the course of the disease and after remission. C1q-binding immune complexes were only found in two patients. These findings suggest that immune complexes-containing IgA may initiate the vasculitis of Henoch-Schönlein purpura, whereas complement-reacted immune complexes containing immunoglobulins of the other classes appear in the circulation in a later phase.

Herpes zoster in patients with treated Wegener's granulomatosis. A possible role for cyclophosphamide

In review of the ongoing protocol for the treatment of Wegener's granulomatosis with cyclophosphamide at te National Institutes of Health, an increased incidence of herpes zoster infection was noted. There were a total of nine episodes in seven of a total of 65 patients with a 255 patient year follow-up. The infections occurred while the patients were in complete clinical remission during immunosuppressive therapy. Cutaneous dissemination was noted in two episodes, but no visceral or central nervous system involvement was noted despite continuation of immunosuppressive therapy. The major causal factor of the increased incidence of herpes zoster appeared to be the cyclophosphamide therapy.

Allergic vasculitis. A histological and immunofluorescent study of lesional and non-lesional skin in relation to circulating immune complexes

This study concerns 57 patients who fulfilled histological criteria for the diagnosis allergic vasculitis. For 37 of these patients, biopsy specimen were available from lesional and adjacent non-lesional skin. Histological signs of vasculitis were found at both sites, but in clinically normal skin the perivascular infiltrate was less dense and neutrophils and eosinophils were sparse or absent. Fibrin was found in only ten patients and occurred less frequently in non-lesional skin. Deposits of immune complexes and/or complement were detected by immunofluorescence in 49 of the 57 patients. Hardly any differences between lesional and non-lesional skin were found with immunofluorescent microscopy. Circulating immune complexes were detected in 45 of the 56 available sera. A relationship was found between the class of immunoglobulin in immune complexes in the vessel wall and in the circulation. Moreover, the class of immunoglobulin seemed to be related to the course, the extracutaneous involvement, and the presence of associated diseases. No explanation was found for the histological differences observed between lesional and non-lesional skin.

Plasma exchange in management of a patient with diffuse necrotizing cutaneous vasculitis

It has been sufficiently established that the so-called small vessel vasculitis results from hypersensitivity reactions to various endogenous or exogenous antigens, and that, in most cases, the pathogenic mechanism is the deposition of immune complexes in the blood vessel wall. Among the therapeutic protocol that have been applied recently, plasma exchange (PE) received little attention, that only a few cases have been treated accordingly until now. Here, we present a patient with diffuse cutaneous necrotizing vasculitis, in whom PE proved to be of irreplaceable benefit in halting the progression of the disease. When PE was discontinued, the disease relapsed in spite of therapy with steroids and heparin. A second series of PE again controlled the disease activity. The authors point out the PE was of unique value pending the effects to treatment with cyclophosphamide, which remains the essential therapeutic agent.

Livedo reticularis and cerebrovascular accidents

Livedo reticularis is a clinical pattern of cutaneous vascular involvement that can be seen in association with many diseases. The association of livedo reticularis and cerebrovascular accidents has been reported rarely in the past. We report on a 52-year-old woman with marked generalized livedo reticularis and cerebrovascular accidents who exhibited endarteritis obliterans without other pathologic changes on histologic examination of the skin. This constellation of findings suggest a primary vasculopathy with rather extensive involvement which merits our attention and further study.

Relapses in Wegener's granulomatosis: the role of infection

Out of 20 relapses that occurred in patients with Wegener's granulomatosis, nine were provoked by bacterial or viral infection. Seven of these occurred during maintenance treatment in response to infection with common pathogens, and treatment of the infection alone was insufficient to produce remission. Circulating immune complexes were seen only in relapses due to infection and rarely in infections that occurred without relapse. A possible mechanism for infection-provoked relapses is that infection-derived complexes reactivate disease; alternatively, the acute-phase or cellular response to infection may enhance quiescent disease. Infection may exacerbate Wegener's granulomatosis and other autoallergic diseases, but whether it does so by a common mechanism is not known and further study is required.

Functional correlates of lung involvement in Wegener's granulomatosis. Use of pulmonary function tests in staging and follow-up

To examine the usefulness of pulmonary function testing in the clinical management of patients with Wegener's granulomatosis, 22 subjects with biopsy proved disease were evaluated using routine functional parameters. Although reduced lung volumes and diffusing capacity occurred frequently, the most common abnormality was in obstruction to airflow. Comparison of these functional parameters with roentgenographic and clinical findings revealed that reduced lung volumes were useful in detecting focal infiltrates, mass or cavitary lesions and diffuse interstitial involvement whereas airflow measurements were useful in detecting focal large airway lesions. In people with evidence of limitation of airflow, respiratory complications frequently developed in the form of acute tracheal obstruction of lobar collapse. In addition, serial evaluation of lung function during treatment revealed that although in most patients lung volumes and airflow obstruction improved or stabilized, a reduction of diffusing capacity was common. These studies suggest that routine pulmonary function testing may be a useful tool in the staging of patients with Wegener's granulomatosis and in following responses to therapy.

Giant cell (cranial) arteritis: a clinical review

Giant cell arteritis is a disease of the elderly which is more common than previously recognized. It is important to be aware of this condition because treatment effectively relieves symptoms and prevents serious complications. The disease is suggested when an elderly patient complains of constitutional symptoms, headache, jaw claudication, or the musculoskeletal manifestations of polymyalgia rheumatica. Abnormalities in temporal arteries or other cranial arteries, or evidence of large vessel involvement may be detected by physical examination. A markedly elevated sedimentation rate in association with other clinical features of the disease strongly suggests giant cell arteritis, but a biopsy should be performed to confirm the diagnosis. Corticosteroid therapy should be started promptly in high doses in order to prevent blindness. Prolonged treatment with lower dose corticosteroids is generally necessary for up to 1 to 2 years, and sometimes longer, for continued symptomatic relief. Long-term follow-up of treated patients has demonstrated no detectable effect on survivorship.

Necrotizing vasculitis

Necrotizing vasculitis is a term used to describe vessel wall necrosis due to neutrophil infiltration. Current evidence strongly suggests that these cells are responding to elaboration of chemotactic factors of the complement cascade released at the site of deposition of immune complexes in the vessel wall. The antibody is usually IgG or IgM (and rarely IgA), but the only antigens identified with even a minimum certainty are the streptococcal M protein, the hepatitis B surface antigen, and Mycobacterium tuberculosis. Vessels may be involved, leading to specific signs or symptoms, in a wide range of organs, but with those of the skin, kidney, joints, and gastrointestinal tract leading the list. Why vessels of different sizes or location become involved in individual patients is unknown. Therapy with nontoxic drugs, such as antihistamines or salicylates, is indicated when the disease is mild, but vital organ involvement may necessitate therapy with systemic corticosteroids and/or cyclophosphamide.

Cutaneous vascular immunofluorescence in rheumatoid arthritis. Correlation with circulating immune complexes and vasculitis

The presence of immunoglobulin and complement in the cutaneous blood vessels of clinically uninvolved forearm skin was studied in 70 patients with rheumatoid arthritis, using immunofluorescent techniques. Patients with evidence of these immune deposits had a greater prevalence of circulating immune complexes, vasculitic skin lesions, subcutaneous nodules, high titer rheumatoid factor and other findings suggestive of active vasculitis. Biopsy of uninvolved forearm skin may be a useful tool in assessing those patients with rheumatoid arthritis suspected of having a systemic vasculitis.

Evaluation of arthritis and arthralgia in the pediatric patient

The records of 250 consecutive children presenting to a university pediatric service with joint complaints of unknown cause were reviewed to determine the frequency of diagnoses and the utility of laboratory data and physical examination findings. Eighteen per cent of children had orthopedic disorders (Group I), 17.6 per cent had autoimmune disorders (Group II), 19.6 per cent had joint complaints related to a bacterial infection (Group III), and 44 per cent had miscellaneous problems (Group IV). Autoimmune or infectious disd/or erythrocyte sedimentation rate was greater than or equal to 30 mm/h was present than if absent (65% vs. 8% respectively); the sensitivity of fever and/or elevated erythrocyte sedimentation rate was 93 per cent for Group II and III patients. The presence of rash was predictive of an autoimmune disorder in 67 per cent of the instances; a positive joint examination was seen disproportionately in Group I patients. A negative joint examination all but ruled out an infectious etiology. Other test results, such as diagnostic radiograms, WBC greater than or equal to 15,000 per cu mm; or a positive ANA or rheumatoid factor were predictive but not sensitive indicators of selected groups. If the tiology of a child's joint complaints is unknown, the likelihood of an orthopedic, autoimmune or infectious disorder may be suggested by reviewing temperature and ESR data and skin and joint findings.

Diffuse intrapulmonary hemorrhage, renal failure and a systemic vasculitis. A case report and review of the literature

A 63 year old women was hospitalized with massive hemoptysis, anemia and renal failure. Despite intensive supportive care, she died soon after admission. Autopsy revealed diffuse necrotizing alveolitis, rapidly progressive glomerulonephritis and a systemic vasculitis. Massive intrapulmonary hemorrhage with hemoptysis is an unusual complication of a systemic vasculitis. The case is discussed and the literature reviewed.

Radiation therapy and mechanical dilation of endobronchial obstruction secondary to Wegener's granulomatosis

A patient with Wegener's granulomatosis, which was otherwise well controlled with steroids and cyclophosphamide, had persistent total obstruction of an inflamed left mainstem bronchus. The inflammation resolved, and the lung expanded following radiation therapy. However, intermittent atelectasis and pneumonia occurred distal to a residual short stricture. Repeated dilation endoscopically with Plummer bougies has proven effective in maintaining good ventilation and preventing recurrence of the atelectasis and pneumonia in the left lung for 18 months.

Necrotizing sarcoid granulomatosis

Twelve cases of necrotizing sarcoid granulomatosis are presented as a retrospective study. The population of patients consisted of ten women and two men, with an average age of 50 years. Nine patients initially had a variety of pulmonary and nonpulmonary complaints, while three were asymptomatic. Chest roentgenograms demonstrated bilateral nodules in seven patients, solitary nodules in four, and a miliary pattern progressing to nodules in one. Enlarged hilar nodes were found in six. Histologically, all biopsies showed a combination of individual granulomas, confluent masses of granulomas which formed the nodular masses seen on the roentgenograms, a variable amount of necrosis of tissue and hyalinization, and a granulomatous vasculitis. Follow-up periods ranged from four months to 11 years. Eleven patients are alive and asymptomatic. The sole death occurred in a patient treated with an immunosuppressive agent (cyclophosphamide). We conclude that the clinical behavior of necrotizing sarcoid granulomatosis is not similar to that of the other angiocentric granulomatoses and that most patients with this disease can be left untreated or be treated with steroids alone. We suggest the possibility that necrotizing sarcoid granulomatosis may be the histologic counterpart of so-called nodular sarcoid.