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Hafner F, Froehlich H, Gary T, Tiesenhausen K, Scarpatetti M, Brodmann M. Blood Pressure Measurements in Patients With Takayasu Arteritis: A Work of Caution. Ann Thorac Surg 2012; 93:1299-301. [DOI: 10.1016/j.athoracsur.2011.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Revised: 07/09/2011] [Accepted: 09/02/2011] [Indexed: 10/28/2022]
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Abstract
Pulmonary vasculitis can occur in apparent isolation, as part of a primary systemic vasculitis, or with an underlying systemic inflammatory autoimmune disorder. The presentation of pulmonary vasculitis in the intensive care unit (ICU) can be fulminant and will often overlap with more common disorders that affect the critically ill. Although diffuse alveolar hemorrhage (DAH) is the clinical feature that often initiates the concern for an underlying vasculitis, hemoptysis may not be apparent or its presentation can be mistaken for an alternative disease process. As a result, the diagnosis of pulmonary vasculitis in the ICU may be delayed or be completely unrecognized. A high level of suspicion is essential to obtain a timely diagnosis and for effective therapies to be implemented. There have been significant advances this past decade in diagnostic strategies as well as in the therapeutic options for patients with pulmonary vasculitis. We review here the clinical presentations, diagnostic strategies, and treatment options of the critically ill patients presenting with pulmonary vasculitis. The reader is referred to other resources for a more comprehensive review of specific vasculitic entities.
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Affiliation(s)
- Jesus Diaz
- Department of Internal Medicine, Division of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL, USA
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54
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Houthuizen P, Polak PE, Edelbroek MAL, Peels CH. Giant cell arteritis as a cardiovascular entity. Neth Heart J 2011; 17:281-3. [PMID: 19789695 DOI: 10.1007/bf03086266] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Giant cell arteritis (GCA) is a relatively infrequent disorder that is underdiagnosed and little appraised in the field of general cardiology. However, it is important to be familiar with the clinical picture of this disease, especially because of the risk of developing fatal aortic aneurysms. If the disease is suspected after a thorough history and clinical examination combined with laboratory investigation, the diagnosis can be confirmed with (18)F-2-deoxy-glucose positron emission tomographic (FDG-PET) imaging. Early recognition of giant cell arteritis followed by prompt treatment with glucocorticosteroids will decrease the risk of developing large-vessel complications. (Neth Heart J 2009;17:281-3.).
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Affiliation(s)
- P Houthuizen
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
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55
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Luqmani R, Suppiah R, Edwards CJ, Phillip R, Maskell J, Culliford D, Jayne D, Morishita K, Arden N. Mortality in Wegener's granulomatosis: a bimodal pattern. Rheumatology (Oxford) 2010; 50:697-702. [DOI: 10.1093/rheumatology/keq351] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
In 1923, Friedrich Wohlwill described two patients with a "microscopic form of periarteritis nodosa," which was distinct from the classical form. This disease, now known as microscopic polyangiitis (MPA), is a primary systemic vasculitis characterized by inflammation of the small-caliber blood vessels and the presence of circulating antineutrophil cytoplasmic antibodies. Typically, microscopic polyangiitis presents with glomerulonephritis and pulmonary capillaritis, although involvement of the skin, nerves, and gastrointestinal tract is not uncommon. Treatment of MPA generally requires use of a cytotoxic agent (such as cyclophosphamide) in addition to high-dose glucocorticoids. Recent research has focused on identifying alternate treatment strategies that minimize or eliminate exposure to cytotoxic agents. This article reviews the history, pathogenesis, clinical manifestations, and treatment of MPA.
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Roghi A, Pedrotti P, Milazzo A, Vignati G, Martinelli L, Paino R, Bonacina E. Acute myocardial infarction and cardiac arrest in atypical Takayasu aortitis in a young girl: unusual diagnostic role of cardiac magnetic resonance imaging in emergency setting. Circulation 2010; 121:e370-5. [PMID: 20385957 DOI: 10.1161/cir.0b013e3181dab9ee] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alberto Roghi
- Noninvasive Cardiac Imaging Laboratories, CMR Unit, Niguarda Ca'Granda Hospital, Milan, Italy.
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58
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Pagnoux C, Seror R, Henegar C, Mahr A, Cohen P, Le Guern V, Bienvenu B, Mouthon L, Guillevin L. Clinical features and outcomes in 348 patients with polyarteritis nodosa: a systematic retrospective study of patients diagnosed between 1963 and 2005 and entered into the French Vasculitis Study Group Database. ACTA ACUST UNITED AC 2010; 62:616-26. [PMID: 20112401 DOI: 10.1002/art.27240] [Citation(s) in RCA: 313] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Previous studies of polyarteritis nodosa (PAN) included patients with microscopic polyangiitis, because these entities were not distinguished prior to the Chapel Hill Consensus Conference (CHCC). This study was undertaken to describe the main characteristics of and long-term outcomes in patients with well-characterized PAN diagnoses. METHODS We conducted a systematic retrospective study of 348 patients who were diagnosed as having PAN between March 1963 and October 2005, were registered in the French Vasculitis Study Group database, and satisfied the American College of Rheumatology and CHCC criteria. Patient characteristics and outcomes were analyzed and compared according to hepatitis B virus (HBV) status. RESULTS At diagnosis, the mean +/- SD age was 51.2 +/- 17.3 years. The most frequent findings were general symptoms (93.1%), neurologic manifestations (79%), skin involvement (49.7%), abdominal pain (35.6%), and hypertension (34.8%); 66.2% had renal artery microaneurysms; 70.1% had histologically proven PAN. Patients with HBV-related PAN (n = 123) had more frequent peripheral neuropathy, abdominal pain, cardiomyopathy, orchitis, and hypertension compared with patients with non-HBV-related PAN (n = 225). During a mean +/- SD followup of 68.3 +/- 63.5 months, 76 patients (21.8%) relapsed (63 with non-HBV-related PAN [28%] versus 13 with HBV-related PAN [10.6%]; P < 0.001); 86 patients (24.7%) died (44 with non-HBV-related PAN [19.6%] versus 42 with HBV-related PAN [34.1%]; P = 0.003). Five-year relapse-free survival rates were 59.4% (95% confidence interval [95% CI] 52.6-67.0) versus 67.0% (95% CI 58.5-76.8) for non-HBV-related PAN and HBV-related PAN, respectively. Multivariate analysis retained age >65 years, hypertension, and gastrointestinal manifestations requiring surgery or at least consultation with a surgeon as independent predictors of death, whereas patients with cutaneous manifestations or non-HBV-related PAN had a higher risk of relapse. CONCLUSION Our findings indicate that the rate of mortality from PAN remains high, especially for the elderly, and relapses do occur, particularly in patients with non-HBV-related PAN with cutaneous manifestations.
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Affiliation(s)
- Christian Pagnoux
- Université Paris Descartes, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France.
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Flynn TR, Hunter GJ, Johnson MM. Case records of the Massachusetts General Hospital. Case 6-2010. A 37-year-old man with a lesion on the tongue. N Engl J Med 2010; 362:740-8. [PMID: 20181976 DOI: 10.1056/nejmcpc0910089] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Thomas R Flynn
- Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, USA
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60
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Grisaru S, Yuen GWH, Miettunen PM, Hamiwka LA. Incidence of Wegener's granulomatosis in children. J Rheumatol 2009; 37:440-2. [PMID: 20032105 DOI: 10.3899/jrheum.090688] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the incidence and longitudinal trends of Wegener's granulomatosis (WG) in the pediatric population of Southern Alberta over the last 15 years. RESULTS Fifteen cases of childhood WG were confirmed. The average annual incidence was 2.75 cases/million/year, with a steep increase over the last 5 years to 6.39 cases/million/year. CONCLUSION In Southern Alberta the incidence of childhood WG during the past 15 years was comparable to the incidence reported in adults and it seems to be increasing. Further studies are required to determine if this is a regional or global phenomenon.
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Affiliation(s)
- Silviu Grisaru
- Division of Pediatric Nephrology, Department of Pediatrics, University of Calgary, Alberta, Canada.
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61
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Mutsaers ER, Witteveen R, van den Bosch-Ruis W, Kuijpers TW, van Houten MA, van den Berg JM. A pseudoleukemic blood differentiation in a 13-year-old child: an extraordinary presentation of Churg-Strauss syndrome. Clin Rheumatol 2009; 32 Suppl 1:S7-9. [PMID: 19756836 PMCID: PMC3594815 DOI: 10.1007/s10067-009-1265-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 08/14/2009] [Indexed: 11/25/2022]
Abstract
Churg-Strauss syndrome (CSS) is a rare systemic vasculitis of the small- and medium-size vessels. It is mostly seen in elderly patients presenting as de novo asthma, eosinophilia, and vasculitic organ involvement. In childhood, CSS is extremely rare. The course of pediatric CSS is usually severe and often lethal. We present a case of a 13-year-old girl with a short history of asthma, marked eosinophilia, and multiorgan involvement. The extremely high level of blood eosinophilic granulocytes (51.6 × 109/L) prompted a workup for eosinophilic leukemia before the diagnosis CSS could be made. Subsequently, the disease was successfully treated. This case report shows a classical case of childhood CSS, remarkable because of the presence of extreme hypereosinophilia. It underlines the importance of CSS as a life-threatening cause of hypereosinophilia in children.
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Affiliation(s)
- E R Mutsaers
- Department of Pediatrics, Spaarne Ziekenhuis, Hoofddorp, The Netherlands
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62
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Abstract
Primary systemic vasculitides of the young are relatively rare diseases, but can have a significant morbidity and mortality. The purpose of this review is to provide an overview of the paediatric vasculitides. Vasculitides that predominantly affect children will be considered in more detail than vasculitic diseases that although are seen in children affect adults more commonly, such as the ANCA associated vasculitides. New classification criteria for childhood vasculitis have recently been proposed and are currently undergoing validation. Epidemiological clues continue to implicate infectious triggers in Kawasaki Disease and Henoch Schönlein purpura. Several genetic polymorphisms have now been described in the vasculitides that may be relevant in terms of disease predisposition or development of disease complications. Treatment regimens continue to improve, with the use of different immunosuppressive medications and newer therapeutic approaches such as biologic agents. However new challenges are looming in regards to the role of inflammation in endothelial health and the long term cardiovascular morbidity for children with primary systemic vasculitis. International multicenter collaboration is of utmost importance in order for us to further advance our understanding and improve the treatment and outcome of systemic vasculitis in the young.
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Affiliation(s)
- Despina Eleftheriou
- Department of Paediatric Rheumatology, Institute of Child Health and Great Ormond St Hospital for Children, London, UK.
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63
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Takala JH, Kautiainen H, Malmberg H, Leirisalo‐Repo M. Wegener's granulomatosis in Finland in 1981–2000: clinical presentation and diagnostic delay. Scand J Rheumatol 2009; 37:435-8. [DOI: 10.1080/03009740802238366] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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65
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Inflammatory vascular diseases. Dermatopathology (Basel) 2009. [DOI: 10.1016/b978-0-7020-3023-9.10011-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Datwyler SA, Hsu SC, Matias MS, Pacenti DP, Shih J. Potential Interference by Antineutrophil Cytoplasmic Autoantibodies in Myeloperoxidase Immunoassays. Clin Chem 2008; 54:2084-6. [DOI: 10.1373/clinchem.2008.110841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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67
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The autoimmunologist: geoepidemiology, a new center of gravity, and prime time for autoimmunity. J Autoimmun 2008; 31:325-30. [DOI: 10.1016/j.jaut.2008.08.004] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 08/10/2008] [Accepted: 08/12/2008] [Indexed: 12/31/2022]
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Srouji I, Lund V, Andrews P, Edwards C. Rhinologic symptoms and quality-of-life in patients with Churg-Strauss syndrome vasculitis. ACTA ACUST UNITED AC 2008; 22:406-9. [PMID: 18702907 DOI: 10.2500/ajr.2008.22.3204] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The purpose of this study was to investigate the presentation pattern, sinonasal symptoms, and quality of life (QOL) in patients with Churg-Strauss syndrome (CSS) vasculitis. METHODS A cross-sectional study was performed. Twenty-five patients with CSS belonging to a patient self-help group participated. Main outcome measures included mode of initial presentation, treatment, rhinologic symptoms, and disease-specific QOL (Sinonasal Outcome Test [SNOT-22] scores) and comparisons were made with general rhinosinusitis and other nasally affected vasculitis patients (Wegener's granulomatosis [WG]). RESULTS Overall, 80% of CSS patients had active sinonasal symptoms at the time of the study. Twenty-eight percent of CSS patients reported worsening of their nasal symptoms as the main event leading to their diagnosis. Forty-eight percent of CSS patients had undergone nasal surgery. Nasal symptoms that are of particular relevance to this patient group are nasal obstruction (95%), rhinorrhea (95%), anosmia (90%), and excessive sneezing (80%). Other symptoms included nasal crusting (75%), purulent nasal discharge (65%), and epistaxis (60%). SNOT-22 scores were significantly higher than normal, reaching average values similar to those of patients from the general rhinosinusitis population. CONCLUSION Sinonasal symptoms are common at initial presentation of CSS, emphasizing the role of otolaryngologists in its diagnosis. Overall, CSS-related sinonasal morbidity is significant and comparable with that of the general rhinosinusitis population. It predominantly results from symptoms of allergic rhinitis, but a significant proportion of CSS patients also report milder forms of crusting, epistaxis, and of purulent sinusitis, symptoms which are more commonly attributed to patients with WG.
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Churg-Strauss syndrome in childhood: a systematic literature review and clinical comparison with adult patients. Semin Arthritis Rheum 2008; 39:108-15. [PMID: 18639318 DOI: 10.1016/j.semarthrit.2008.05.004] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Revised: 05/05/2008] [Accepted: 05/24/2008] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe the clinical characteristics of children with Churg-Strauss syndrome (CSS) in comparison with adult patients. MATERIALS AND METHODS A systematic literature analysis was performed in the Medline database up to November 2007 and in rheumatology and pulmonology meeting scientific abstracts 2003-2007. Articles with reported childhood CSS cases were retrieved; clinical data were recorded. Descriptive statistical analyses and a comparison with 2 published adult CSS cohorts were performed. RESULTS Thirty-three cases of childhood CSS were identified. The mean age was 12 years and the male-to-female ratio was 0.74. All patients had significant eosinophilia and asthma. Histological evidence of eosinophilia and/or vasculitis was present in virtually all patients. Antineutrophil cytoplasmic antibodies were found in 25% of children with CSS. Initial treatment was corticosteroid monotherapy in 76% of childhood CSS patients, while 24% received additional immunosuppressive therapy. Another 18% required further immunosuppression at follow-up due to frequent relapses. Six deaths (18%), all related to the underlying disease, occurred after a mean disease duration of 14 months. As compared with adult CSS patients, children had a predominance of cardiopulmonary disease manifestations, a lower rate of peripheral nerve involvement, and higher mortality. CONCLUSIONS Many aspects of CSS are similar in childhood and adult patients. However, pulmonary and cardiac involvement is predominant in pediatric CSS and mortality is substantial.
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Affiliation(s)
- Heather L Gornik
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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71
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Challenges in the management of microscopic polyangiitis: past, present and future. Curr Opin Rheumatol 2008; 20:3-9. [DOI: 10.1097/bor.0b013e3282f370d1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Grosse-Wortmann L, Grabitz R, Seghaye MC. Magnetic guide-wire navigation in pulmonary and systemic arterial catheterization: initial experience in pigs. J Vasc Interv Radiol 2007; 18:545-51. [PMID: 17446546 DOI: 10.1016/j.jvir.2007.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Cardiovascular catheterization can be challenging whenever a stenosis or an abnormal vascular course interferes with probing the target vessel. This study addresses the feasibility of navigating a guide wire with a magnetic tip by an external magnetic field through pulmonary and systemic arteries in an experimental porcine model. MATERIALS AND METHODS We investigated six piglets using magnetic guide-wire navigation. Two pulmonary arteriograms were taken from different angles in order to reconstruct the three-dimensional vessel anatomy. A computer interface then calculated three-dimensional coordinates for the vessel in space. Using these coordinates, two external magnets were positioned to create magnetic vectors along the expected vessel course. Magnetically enabled guide wires were then navigated into the vessels using the magnetic field to orient the guide-wire tips. Aortic and renal branches were addressed in a similar fashion. Difficulty in reaching the target vessel was reflected by the number of attempts that were necessary. After 10 failed attempts, the maneuver was recorded to have failed. RESULTS Thirty-five of 37 (94.6%) arteries with branches at acute angles were reached successfully using magnetic navigation. In two pigs, the left upper lobe artery could not be probed. Peripheral arteries of small diameter were easier to reach than large central arteries, requiring less attempts. CONCLUSIONS Magnetic guide-wire navigation is feasible in the arteries of the lungs, the head and neck, and the kidneys. It is particularly useful in entering small arterial branches at acute angles and may facilitate interventional therapy in a variety of vascular diseases in children and adults.
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Affiliation(s)
- Lars Grosse-Wortmann
- Department of Pediatric Cardiology, Aachen University Hospital, Pauwelsstrasse 30, 52057 Aachen, Germany.
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Boltin D, Wollman J, Anouk M, Goor Y, Ablin J, Gur HG, Caspi D, Elkayam O. Large aorta and narrow arteries: two short stories of too long diagnostic delay. Rheumatol Int 2007; 27:985-7. [PMID: 17370073 DOI: 10.1007/s00296-007-0326-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2006] [Accepted: 02/24/2007] [Indexed: 10/23/2022]
Abstract
The diagnosis of Takayasu arteritis requires a high degree of clinical suspicion. We herein present two cases of Takayasu arteritis that demonstrate two important aspects of the disease, which leaded to a significant delay in the diagnosis. The first case presented with an indolent disease with a clinical course of 20 years until clinical diagnosis was finally established while the second case shows the commonly unrecognised aspect of severe renovascular hypertension in these patients.
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Affiliation(s)
- Doron Boltin
- Department of Internal Medicine F, Tel Aviv Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, 64239 Tel Aviv, Israel
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Srouji I. Leukotriene receptor antagonists and rhinitis: uncharted territory. Clin Otolaryngol 2007; 32:69-70; author reply 70-1. [PMID: 17298322 DOI: 10.1111/j.1365-2273.2007.01357.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Srouji IA, Andrews P, Edwards C, Lund VJ. General and Rhinosinusitis-Related Quality of Life in Patients With Wegener???s Granulomatosis. Laryngoscope 2006; 116:1621-5. [PMID: 16954992 DOI: 10.1097/01.mlg.0000230440.83375.4b] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives of this cross-sectional study were to outline the pattern of sinonasal morbidity and determine its effects on the quality of life (QOL) of patients with Wegener's granulomatosis (WG). METHODS The authors conducted a survey of 199 patients with WG, including two validated (QOL) instruments to assess general (SF-36) and rhinosinusitis-specific quality of life (Sinonasal Outcome Test [SNOT-22]). RESULTS Patients with WG who have sinonasal involvement reported significantly lower general QOL scores than their unaffected counterparts (P = .000006-0.04) for all SF-36 subsets except for emotional role. WG-related sinonasal morbidity was comparable to the high levels previously demonstrated in the general rhinosinusitis population. A total of 38.2% of all patients with WG reported a nasal symptom as their most troublesome from a list of nasal and constitutional symptoms. Twenty-three percent of all patients with WG rated nasal crusting and 17% rated epistaxis as one of their top three most troublesome symptoms even in the setting of multisystem disease. The inclusion of crusting, bleeding, and nasal deformity in the SNOT scoring significantly increased average scores of patients with WG (P = .024, paired t test). CONCLUSIONS Sinonasal involvement impacts significantly on the general QOL of patients with WG and is at least as significant as that of the general rhinosinusitis population. Nasal symptoms that are of particular relevance to this patient group include nasal crusting and epistaxis.
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Affiliation(s)
- I A Srouji
- ENT Department, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
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