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Pella E, Iatridi F, Sgouropoulou V, Boutou A, Dimitroulas T. Pulmonary involvement in antineutrophil cytoplasmic antibody-associated vasculitides. Int J Rheum Dis 2024; 27:e14933. [PMID: 37753535 DOI: 10.1111/1756-185x.14933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/04/2023] [Indexed: 09/28/2023]
Affiliation(s)
- Eva Pella
- First Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Fotini Iatridi
- First Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Sgouropoulou
- First Department of Pediatrics, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Afroditi Boutou
- Department of Respiratory Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros Dimitroulas
- Forth Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Mohamadi A, Soroureddin S, Nayebirad S, Tamartash Z, Mohebbi M, Kavosi H. New-onset ANCA-associated vasculitis presenting with neuropathy after COVID-19 infection: A case report and literature review. Clin Case Rep 2024; 12:e8457. [PMID: 38259866 PMCID: PMC10801276 DOI: 10.1002/ccr3.8457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/10/2023] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Coronavirus Disease 2019 (COVID-19) is a viral infection caused by SARS-CoV-2, which can trigger autoimmune diseases such as antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis (AAV) that affect small and medium-sized blood vessels in multiple organs. This study discusses a case with neuropathy and positive ANCA after COVID-19 infection and reviews the literature on AAV following COVID-19 infection. A 59-year-old man is presented that was referred to Shariati Hospital for evaluation of neurologic problems after a COVID-19 infection. Initially, he had flu-like symptoms. A few days later, he developed right distal upper and lower limb paresthesia. His electromyography (EMG) and nerve conduction velocity (NCV) results were consistent with polyneuropathy. Lumbar puncture (LP) was normal except for positive COVID-19 polymerase chain reaction (PCR). The patient's paresthesia worsened. Laboratory data showed leukocytosis, anemia, thrombocytosis, high erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Perinuclear anti-neutrophil cytoplasmic antibody (MPO-ANCA) was positive. According to the results, vasculitis was the main differential diagnosis. The sural nerve biopsy was performed, and the result was consistent with small to medium-sized vessel vasculitis. The patient was diagnosed with COVID-induced AAV. He was prescribed methylprednisolone and cyclophosphamide and was discharged with prednisolone and cotrimoxazole. In this study, a unique case of AAV induced by COVID-19 infection confirmed by nerve biopsy is presented. A review of the literature found 48 cases of new-onset AAV in adults and pediatrics after COVID-19 infection. Further research is needed to completely understand the relationship between COVID-19.
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Affiliation(s)
- Aida Mohamadi
- Rheumatology Research CenterTehran University of Medical SciencesTehranIran
| | | | - Sepehr Nayebirad
- Tehran Heart Center, Cardiovascular Diseases Research InstituteTehran University of Medical SciencesTehranIran
| | - Zahra Tamartash
- Rheumatology Research CenterTehran University of Medical SciencesTehranIran
| | - Maryam Mohebbi
- Rheumatology Research CenterTehran University of Medical SciencesTehranIran
| | - Hoda Kavosi
- Rheumatology Research CenterTehran University of Medical SciencesTehranIran
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Higashida-Konishi M, Akiyama M, Hama S, Oshige T, Izumi K, Oshima H, Okano Y. Successful treatment of PR3-ANCA-positive interstitial pneumonia with a moderate dose of glucocorticoid and rituximab. Mod Rheumatol Case Rep 2023; 8:137-140. [PMID: 37225939 DOI: 10.1093/mrcr/rxad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/04/2023] [Accepted: 04/20/2023] [Indexed: 05/26/2023]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-positive interstitial pneumonia (IP) is reported as IP that is ANCA-positive and does not involve organ damage associated with vasculitis other than the lungs. While the combination of glucocorticoid and rituximab is effective in ANCA-associated vasculitis, the treatment strategy for ANCA-positive IP has not been established. Here, we report the first case of successful treatment of proteinase 3 (PR3)-ANCA-positive IP with a moderate dose of glucocorticoid and rituximab. The patient was an 80-year-old male who presented with subacute dry cough and dyspnoea. Blood tests revealed elevated levels of C-reactive protein, Krebs von den Lungen 6 (KL-6), and PR3-ANCA. Chest computed tomography (CT) showed interstitial shadows and infiltrates around honeycomb cysts. 18F-fluorodeoxyglucose (FDG) positron emission tomography CT revealed an uptake of FDG in the IP area. After starting treatment with a moderate dose of prednisolone and rituximab, the patient's clinical symptoms disappeared, C-reactive protein and KL-6 turned to be normal, and infiltrates around the cysts of honeycomb lungs disappeared. Prednisolone was gradually decreased to 2 mg, and no relapse or adverse events were observed during the course of treatment. Our case suggests that early treatment with a moderate dose of glucocorticoid and rituximab is effective for PR3-ANCA-positive IP.
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Affiliation(s)
- Misako Higashida-Konishi
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Mitsuhiro Akiyama
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Hama
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Tatsuhiro Oshige
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Keisuke Izumi
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hisaji Oshima
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yutaka Okano
- Division of Rheumatology, Department of Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
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Uccello G, Bonacchi G, Rossi VA, Montrasio G, Beltrami M. Myocarditis and Chronic Inflammatory Cardiomyopathy, from Acute Inflammation to Chronic Inflammatory Damage: An Update on Pathophysiology and Diagnosis. J Clin Med 2023; 13:150. [PMID: 38202158 PMCID: PMC10780032 DOI: 10.3390/jcm13010150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
Acute myocarditis covers a wide spectrum of clinical presentations, from uncomplicated myocarditis to severe forms complicated by hemodynamic instability and ventricular arrhythmias; however, all these forms are characterized by acute myocardial inflammation. The term "chronic inflammatory cardiomyopathy" describes a persistent/chronic inflammatory condition with a clinical phenotype of dilated and/or hypokinetic cardiomyopathy associated with symptoms of heart failure and increased risk for arrhythmias. A continuum can be identified between these two conditions. The importance of early diagnosis has grown markedly in the contemporary era with various diagnostic tools available. While cardiac magnetic resonance (CMR) is valid for diagnosis and follow-up, endomyocardial biopsy (EMB) should be considered as a first-line diagnostic modality in all unexplained acute cardiomyopathies complicated by hemodynamic instability and ventricular arrhythmias, considering the local expertise. Genetic counseling should be recommended in those cases where a genotype-phenotype association is suspected, as this has significant implications for patients' and their family members' prognoses. Recognition of the pathophysiological pathway and clinical "red flags" and an early diagnosis may help us understand mechanisms of progression, tailor long-term preventive and therapeutic strategies for this complex disease, and ultimately improve clinical outcomes.
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Affiliation(s)
- Giuseppe Uccello
- Division of Cardiology, Alessandro Manzoni Hospital—ASST Lecco, 23900 Lecco, Italy;
| | - Giacomo Bonacchi
- Division of Cardiology, Tor Vergata University Hospital, 00133 Rome, Italy;
| | | | - Giulia Montrasio
- Inherited Cardiovascular Diseases Unit, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BS, UK;
| | - Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy
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Sada KE, Kaname S, Higuchi T, Furuta S, Nagasaka K, Nanki T, Tsuboi N, Amano K, Dobashi H, Hiromura K, Bando M, Wada T, Arimura Y, Makino H, Harigai M. Validation of new ACR/EULAR 2022 classification criteria for anti-neutrophil cytoplasmic antibody-associated vasculitis. Mod Rheumatol 2023; 34:144-150. [PMID: 36715080 DOI: 10.1093/mr/road017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/08/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The objective of this study was to compare the American College of Rheumatology/European Alliance of Associations for Rheumatology 2022 criteria with the previous classification algorithm for anti-neutrophil cytoplasmic antibody-associated vasculitis. METHODS We used data from two nationwide, prospective, inception cohort studies. The enrolled patients were classified as having eosinophilic granulomatosis with polyangiitis (EGPA), granulomatosis with polyangiitis (GPA), or microscopic polyangiitis (MPA) according to the new criteria; these criteria were compared with Watts' algorithm. RESULTS Among 477 patients, 10.7%, 9.9%, and 75.6% were classified as having EGPA, GPA, and MPA, respectively; 6.1% were unclassifiable. Three patients met both the EGPA and MPA criteria, and eight patients met both the GPA and MPA criteria. Of 78 patients with GPA classified using Watts' algorithm, 27 (34.6%) patients were reclassified as having MPA. Ear, nose, and throat involvement was significantly less frequent in patients reclassified as having MPA than in those reclassified as having GPA. Of 73 patients unclassifiable using Watts' algorithm, 62 were reclassified as having MPA. All patients reclassified as having MPA were myeloperoxidase-anti-neutrophil cytoplasmic antibody positive, and 46 had interstitial lung disease. CONCLUSION Although the American College of Rheumatology/European Alliance of Associations for Rheumatology 2022 criteria cause overlapping multiple criteria fulfilments in some patients, those items contribute to classifying unclassifiable patients using Watts' algorithm into MPA.
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Affiliation(s)
- Ken-Ei Sada
- Department of Clinical Epidemiology, Kochi Medical School, Nankoku, Japan
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shinya Kaname
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Tomoaki Higuchi
- Division of Multidisciplinary Management of Rheumatic Diseases, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University, Chiba, Japan
| | - Kenji Nagasaka
- Department of Rheumatology, Ome Municipal General Hospital, Ome, Japan
- Department of Rheumatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshihiro Nanki
- Division of Rheumatology, Department of Internal Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Naotake Tsuboi
- Department of Nephrology, Graduate School of Medicine, Fujita Health University, Toyoake, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Hiroaki Dobashi
- Division of Hematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Keiju Hiromura
- Department of Nephrology and Rheumatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Masashi Bando
- Division of Pulmonary Medicine, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | | | - Yoshihiro Arimura
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
- Kichijoji Asahi Hospital, Musashino, Japan
| | | | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Moronti V, Carubbi F, Sollima L, Piscitani L, Ferri C. End stage renal disease in patient with microscopic polyangiitis and atypical hemolytic-uremic syndrome arose 3 weeks after the third dose of anti-SARS-CoV2 vaccine mRNA-1273: A case report with literature revision. Medicine (Baltimore) 2023; 102:e36560. [PMID: 38115241 PMCID: PMC10727565 DOI: 10.1097/md.0000000000036560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/09/2023] [Accepted: 11/20/2023] [Indexed: 12/21/2023] Open
Abstract
RATIONALE Immune system deregulation, including AAV, is a key event that may potentially evolve into ESRD. Abnormal activation of the cAP is also a cardinal feature of TMA, particularly aHUS. The kidney is the most frequently involved organ, and renal-limited forms of TMA are often encountered in clinical practice. Isolated case reports described the occurrence of renal TMA in AAV patients. Some cases of both de novo and relapses of AAV and/or TMAs after anti-SARS-CoV2 vaccination have been reported. We reported, for the 1st time, a case of patients with new-onset MPA and aHUS occurring 3 weeks after the third dose of mRNA-1273 vaccine anti-SARS-CoV2. PATIENT CONCERNS We present a 67-year-old man, affected by arterial hypertension, reported, after mRNA-1273 vaccine anti-SARS-CoV2, anuria, fatigue, anorexia and nausea. Laboratory data revealed acute renal failure. DIAGNOSIS Positivity of MPO-ANCA was observed. 7 days after admission, we observed a worsening of anemia and thrombocytopenia with haptoglobin reduction, LDH increase and presence of schistocytes. Plasma levels of ADAMTS-13 were normal. A renal biopsy was performed, and findings were consistent with microscopic polyangiitis, with features of micro-thrombotic glomerulopathy. Genetic tests revealed absence of hybrid genes associated with the increased risk of aHUS. INTERVENTIONS AND OUTCOMES We started renal replacement treatment, including hemodialysis, and pulsed methylprednisolone, with no improvement of laboratory parameters. Then, plasma exchange was performed leading to partial haematological response. Only with Eculizumab, a human C5 inhibitor, we observed a normalization of haptoglobin levels and platelets' count. However, three months after discharge, the patient still required hemodialysis. LESSONS To our knowledge we observed the first case aHUS, without genetic predisposition, associated with MPA occurring after the third dose of anti-SARS-CoV2 vaccine. This case report highlights the potential link between anti-SARS-CoV2 vaccine as a trigger of MPA and aHUS. This systematic review offers additional perspectives. It is plausible to hypothesize that the vaccine was the trigger for the development of these 2 diseases.Solid evidence on the mechanisms of interaction between vaccine and immune system, the role of genetic predisposition, and other variables, will shed additional light on the controversial link between anti-SARS-CoV2 vaccine and autoimmunity.
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Affiliation(s)
- Veronica Moronti
- University of L’Aquila, Department of Life, Health and Environmental Sciences; Internal Medicine and Nephrology Division, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
| | - Francesco Carubbi
- University of L’Aquila, Department of Life, Health and Environmental Sciences; Internal Medicine and Nephrology Division, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
| | - Laura Sollima
- Anatomy and Pathological Histology Division, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
| | - Luca Piscitani
- Nephrology and Dialysis Division, Department of Medicine, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
| | - Claudio Ferri
- University of L’Aquila, Department of Life, Health and Environmental Sciences; Internal Medicine and Nephrology Division, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
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Ha JW, Ahn SS, Song JJ, Park YB, Lee SW. Clinical implications of peripheral eosinophil count at diagnosis in patients newly diagnosed with microscopic polyangiitis and granulomatosis with polyangiitis. Arthritis Res Ther 2023; 25:245. [PMID: 38102670 PMCID: PMC10722771 DOI: 10.1186/s13075-023-03233-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND This study investigated the clinical implications of peripheral eosinophil count at diagnosis in estimating cross-sectional antineutrophil cytoplasmic antibody-associated vasculitis (AAV) activity and predicting all-cause mortality during follow-up in patients newly diagnosed with microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA). METHODS This study included 224 immunosuppressive drug-naïve patients with peripheral eosinophil count at diagnosis < 1,000/mm3. The Birmingham Vasculitis Activity Score (BVAS), the Five-Factor Score (FFS), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) at diagnosis were assessed. RESULTS The median age of the 224 patients (152 MPA and 72 GPA) was 62.0 years; 35.3% of them were men. At diagnosis, peripheral eosinophil count was significantly correlated with BVAS (P = 0.001), FFS (P = 0.046), ESR (P < 0.001), and CRP (P < 0.001). Deceased patients had a significantly higher median peripheral eosinophil count at diagnosis than surviving patients (310.0/mm3 vs. 170.0/mm3, P = 0.004). In addition, patients with MPA and those with cardiovascular and renal manifestations at diagnosis exhibited significantly higher peripheral eosinophil counts than those without. When the optimal cut-off of peripheral eosinophil count at diagnosis for all-cause mortality during follow-up was set at 175.0/mm3, Patients with peripheral eosinophil count at diagnosis ≥ 175.0/mm3 exhibited a significantly lower cumulative patients' survival rate than those with peripheral eosinophil count at diagnosis < 175.0/mm3 (P = 0.008). CONCLUSIONS This study was the first to demonstrate that peripheral eosinophil count at diagnosis could estimate cross-sectional AAV activity at diagnosis and contribute to predicting all-cause mortality during follow-up in MPA and GPA patients.
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Affiliation(s)
- Jang Woo Ha
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Soo Ahn
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Walulik A, Łysak K, Błaszkiewicz M, Górecki I, Gomułka K. The Role of Neutrophils in ANCA-Associated Vasculitis: The Pathogenic Role and Diagnostic Utility of Autoantibodies. Int J Mol Sci 2023; 24:17217. [PMID: 38139045 PMCID: PMC10743134 DOI: 10.3390/ijms242417217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/01/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
Recent years have brought progress in understanding the role of the neutrophil, dispelling the dogma of homogeneous cells mainly involved in the prime defence against pathogens, shedding light on their pathogenic role in inflammatory diseases and on the importance of antineutrophil-cytoplasmic antibodies' pathogenic role in ANCA-associated vasculitides vasculitis (AAV). Myeloperoxidase (MPO) and proteinase 3 (PR3) expressed in neutrophil granulocytes are the most common targets for ANCAs and contribute to the formation of MPO-ANCAs and PR3-ANCAs which, released to the bloodstream, become an excellent diagnostic tool for AAV. In this study, we focus on increasing the clinical and experimental evidence that supports the pathogenic role of ANCAs in AAV. Additionally, we discuss the diagnostic utility of ANCAs for disease activity and prognosis in AAV. Understanding the central role of ANCAs in AAV is crucial for advancing our knowledge of these complex disorders and developing targeted therapeutic strategies in the era of personalized medicine.
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Affiliation(s)
- Agata Walulik
- Student Scientific Group of Adult Allergology and Internal Medicine, Wroclaw Medical University, 50-369 Wrocław, Poland; (A.W.); (I.G.)
| | - Kinga Łysak
- Faculty of Medicine, Medical University of Gdansk, 80-210 Gdańsk, Poland;
| | - Michał Błaszkiewicz
- Student Scientific Group of Adult Allergology and Internal Medicine, Wroclaw Medical University, 50-369 Wrocław, Poland; (A.W.); (I.G.)
| | - Ignacy Górecki
- Student Scientific Group of Adult Allergology and Internal Medicine, Wroclaw Medical University, 50-369 Wrocław, Poland; (A.W.); (I.G.)
| | - Krzysztof Gomułka
- Department of Internal Medicine, Pneumology and Allergology, Wroclaw Medical University, 50-369 Wrocław, Poland
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Puapatanakul P, Banjongjit A, Srisawat N, Townamchai N, Kanjanabuch T. A Case of Extranodal NK/T-cell Lymphoma Infiltrating Kidneys, Presenting With Hematuria and Proteinuria With False-Positive Serum Anti-proteinase 3, and Mimicking Granulomatosis With Polyangiitis. Cureus 2023; 15:e49794. [PMID: 38161567 PMCID: PMC10757817 DOI: 10.7759/cureus.49794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
We report a case of misdiagnosed extranodal NK/T-cell lymphoma, nasal type, mimicking granulomatosis with polyangiitis (GPA). A 30-year-old male presented with chronic non-resolving right paranasal sinusitis for two years accompanied by multiple generalized cutaneous nodules, and subnephrotic-range proteinuria. Biopsies from skin lesions and paranasal sinuses demonstrated leukocytoclastic vasculitis and necrotizing granulomatous inflammation, respectively. Serum proteinase 3 (PR3)-antineutrophilic cytoplasmic antibody (ANCA) was positive, suggesting the diagnosis of GPA based on the 2022 American College of Rheumatology/European Alliance of Associations for Rheumatology Classification Criteria for GPA. A kidney biopsy was not pursued due to the cause of glomerulonephritis (GN) being clinically evident, per the KDIGO 2021 GN Clinical Practice Guidelines. Immunosuppression was administered, which led to a transient improvement in clinical symptoms. However, subsequent kidney biopsy and other organ biopsies with cytogenic and molecular tests eventually confirmed extranodal NK/T-cell lymphoma infiltrating kidneys, skin, and paranasal sinuses. Physicians should always consider the possibility of hematologic malignancy in young adults presenting with multiple-organ involvement with vasculitic lesions or pauci-immune crescentic GN, albeit positive ANCA serologies. Kidney biopsy with cytogenic support should be performed to exclude threatening diseases, especially in atypical cases such as in young patients despite a context of compatible manifestations with other syndromes.
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Affiliation(s)
- Pongpratch Puapatanakul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, THA
| | | | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, THA
| | - Natavudh Townamchai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, THA
- Renal Immunology and Renal Transplant Research Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, THA
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, THA
- Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, THA
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van Leeuwen JR, Hafemann S, van der Boog P, van der Woude D, Rabelink T, Teng YKO. The impact of reclassification by the 2022 ACR/EULAR classification criteria on risk factors for relapse in patients with ANCA-associated vasculitis. Clin Kidney J 2023; 16:2754-2756. [PMID: 38045999 PMCID: PMC10690075 DOI: 10.1093/ckj/sfad225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Indexed: 12/05/2023] Open
Affiliation(s)
- Jolijn R van Leeuwen
- Center of Expertise for Lupus-, Vasculitis- and Complement-Mediated Systemic Diseases (LuVaCs), Department of Internal Medicine – Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophia Hafemann
- Center of Expertise for Lupus-, Vasculitis- and Complement-Mediated Systemic Diseases (LuVaCs), Department of Internal Medicine – Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul van der Boog
- Center of Expertise for Lupus-, Vasculitis- and Complement-Mediated Systemic Diseases (LuVaCs), Department of Internal Medicine – Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Diane van der Woude
- Center of Expertise for Lupus-, Vasculitis- and Complement-Mediated Systemic Diseases (LuVaCs), Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ton Rabelink
- Center of Expertise for Lupus-, Vasculitis- and Complement-Mediated Systemic Diseases (LuVaCs), Department of Internal Medicine – Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Y K Onno Teng
- Center of Expertise for Lupus-, Vasculitis- and Complement-Mediated Systemic Diseases (LuVaCs), Department of Internal Medicine – Nephrology Section, Leiden University Medical Center, Leiden, The Netherlands
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Yoon T, Ahn SS, Ko E, Song JJ, Park YB, Lee SW. IL-6 Receptor Expression on the Surface of T Cells and Serum Soluble IL-6 Receptor Levels in Patients with Microscopic Polyangiitis and Granulomatosis with Polyangiitis. J Clin Med 2023; 12:7059. [PMID: 38002672 PMCID: PMC10672709 DOI: 10.3390/jcm12227059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/08/2023] [Accepted: 11/11/2023] [Indexed: 11/26/2023] Open
Abstract
We investigated the IL-6 receptor (IL-6R) expression on the surface of T cells isolated from peripheral blood mononuclear cells (PBMCs) of microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) patients and measured the serum soluble IL-6R (sIL-6R) levels in these patients. Sera and PBMCs were obtained from 51 patients with MPA (n = 32) and GPA (n = 19), with 25 patients having active disease (defined as a Birmingham Vasculitis Activity Score [BVAS] ≥ 5). The median age of patients was 67.0 years, and 52.9% were women. Serum IL-6 levels were significantly correlated with the BVAS (r = 0.384); however, IL-6R expression on the surface of T cells did not significantly differ based on disease activity. Meanwhile, IL-6R expression on the surface of stimulated CD4+ (median mean fluorescence intensity [MFI] 588.0 vs. 1314.8; p < 0.001), CD4+CD25+ (MFI 853.3 vs. 1527.3; p < 0.001), and CD4+CD45RO+ (MFI 679.5 vs. 1241.5; p < 0.001) T cells was significantly reduced compared with unstimulated conditions. Conversely, patients with active disease exhibited a significantly higher median serum sIL-6R level than those with inactive disease (38.1 ng/mL vs. 34.7 ng/mL; p = 0.029). These results imply that the trans-signalling IL-6 pathway may be more activated than the classical signalling pathway in patients with MPA and GPA, suggesting the therapeutic potential of targeting sIL-6R.
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Affiliation(s)
- Taejun Yoon
- BK21 Plus Project, Department of Medical Science, College of Medicine, Yonsei University, Seoul 03772, Republic of Korea
| | - Sung Soo Ahn
- Division of Rheumatology, Department of Internal Medicine, Yongin Severance Hospital, College of Medicine, Yonsei University, Yongin 16995, Republic of Korea
| | - Eunhee Ko
- BK21 Plus Project, Department of Medical Science, College of Medicine, Yonsei University, Seoul 03772, Republic of Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Severance Hospital, College of Medicine, Yonsei University, Seoul 03772, Republic of Korea
- Institute for Immunology and Immunological Diseases, College of Medicine, Yonsei University, Seoul 03772, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Severance Hospital, College of Medicine, Yonsei University, Seoul 03772, Republic of Korea
- Institute for Immunology and Immunological Diseases, College of Medicine, Yonsei University, Seoul 03772, Republic of Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Severance Hospital, College of Medicine, Yonsei University, Seoul 03772, Republic of Korea
- Institute for Immunology and Immunological Diseases, College of Medicine, Yonsei University, Seoul 03772, Republic of Korea
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Jacquot R, Jamilloux Y, Bert A, Gerfaud-Valentin M, Richard-Colmant G, Kodjikian L, Sève P. Etiological Diagnosis of Uveitis: Contribution of the of the Extra-Ophthalmological Clinical Examination. Ocul Immunol Inflamm 2023:1-12. [PMID: 37948510 DOI: 10.1080/09273948.2023.2276304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/22/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE Determining uveitis etiology is a challenge. It is based primarily on demographic data and the characteristics of eye examination. It is not clear to what extent extraocular physical signs contribute to elucidating the etiology. This study aimed to establish the contribution of the clinical extra-ophthalmological features for the assessment of the underlying etiology of uveitis. METHODS We retrospectively reviewed 1307 patients with uveitis referred to our tertiary center between 2003 and 2021. Uveitis was classified according to the Standardization of Uveitis Nomenclature. Clinical features were collected at diagnosis by internists before the etiological diagnosis was made. The main outcome description was the contribution of clinical features. RESULTS Clinical extra-ophthalmological features contributed to the assessment of the underlying etiology of uveitis in 363 (27.8%) patients. The joint and the skin examinations were the most useful for etiological investigations, respectively in 12.3% and 11.8% of patients. Five etiologies of uveitis accounted for 80% of the cases: sarcoidosis, HLA-B27-related uveitis, Behçet's disease, multiple sclerosis, and Vogt-Koyanagi-Harada disease. Clinical extra-ophthalmological features were particularly important in the etiological diagnosis of acute bilateral anterior uveitis and panuveitis. CONCLUSION This study suggests that clinical extra-ophthalmological features are essential for the etiological diagnosis of uveitis in more than a quarter of patients. It demonstrates once again the value of collaboration between ophthalmologists and other specialists experienced in performing extra-ophthalmological clinical examinations, particularly in patients with acute bilateral anterior uveitis and panuveitis.
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Affiliation(s)
- Robin Jacquot
- Department of Internal Medicine, Hôpital Universitaire de la Croix-Rousse, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France
| | - Yvan Jamilloux
- Department of Internal Medicine, Hôpital Universitaire de la Croix-Rousse, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
- Immunopathology Department, Lyon Immunopathology FEderation (LIFE), Lyon, France
| | - Arthur Bert
- Department of Internal Medicine, Hôpital Universitaire de la Croix-Rousse, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, Hôpital Universitaire de la Croix-Rousse, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Gaëlle Richard-Colmant
- Department of Internal Medicine, Hôpital Universitaire de la Croix-Rousse, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Laurent Kodjikian
- Department of Ophthalmology, Hôpital Universitaire de la Croix-Rousse, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
- UMR5510 MATEIS, CNRS, INSA Lyon, University Claude Bernard Lyon 1, Villeurbanne, France
| | - Pascal Sève
- Department of Internal Medicine, Hôpital Universitaire de la Croix-Rousse, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France
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Sorin B, Iudici M, Guerry MJ, Samson M, Bielefeld P, Maillet T, Nouvier M, Karras A, Meyer L, Lavigne C, Régent A, Durel CA, Fabre M, Charles P, Raimbourg Q, Lanteri A, Pugnet G, Rivière F, Pineton de Chambrun M, Cacoub P, Le Guenno G, Jourdain P, Mekinian A, Paule R, Dion J, Legendre P, Cohen P, Guillevin L, Puéchal X, Terrier B. Induction failure in granulomatosis with polyangiitis: a nationwide case-control study of risk factors and outcomes. Rheumatology (Oxford) 2023; 62:3662-3671. [PMID: 36847447 DOI: 10.1093/rheumatology/kead098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/08/2023] [Accepted: 02/20/2023] [Indexed: 03/01/2023] Open
Abstract
OBJECTIVE To identify characteristics of granulomatosis with polyangiitis (GPA) associated with induction failure, describe salvage therapies and their efficacy. METHODS We conducted a nationwide retrospective case-control study of GPA with induction failure between 2006 and 2021. Each patient with induction failure was randomly paired to three controls matched for age, sex and induction treatment. RESULTS We included 51 patients with GPA and induction failure (29 men and 22 women). At induction therapy, median age was 49 years. Twenty-seven patients received intravenous cyclophosphamide (ivCYC) and 24 rituximab (RTX) as induction therapy. Patients with ivCYC induction failure more frequently had PR3-ANCA (93% vs 70%, P = 0.02), relapsing disease (41% vs 7%, P < 0.001) and orbital mass (15% vs 0%, P < 0.01) compared with controls. Patients with disease progression despite RTX induction therapy more frequently had renal involvement (67% vs 25%, P = 0.02) with renal failure (serum creatinine >100 µmol/l in 42% vs 8%, P = 0.02) compared with controls. After salvage therapy, remission was achieved at 6 months in 35 (69%) patients. The most frequent salvage therapy was switching from ivCYC to RTX (or vice versa), showing an efficacy in 21/29 (72%). Remission was achieved in nine (50%) patients with inappropriate response to ivCYC, while in patients with progression after RTX induction, remission was achieved in four (100%) who received ivCYC (with or without immunomodulatory therapy), but only in three (50%) after adding immunomodulatory therapy alone. CONCLUSION In patients with induction failure, characteristics of GPA, salvage therapies and their efficacy vary according to induction therapy and failure modality.
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Affiliation(s)
- Boris Sorin
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Michele Iudici
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
- Division of Rheumatology, Department of Internal Medicine and Department of Medicine, Faculty of Medicine, Geneva University Hospitals, Geneve, Switzerland
| | - Mary-Jane Guerry
- Department of Nephrology, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, Hôpital François Mitterrand, Dijon, France
| | - Philip Bielefeld
- Department of Nephrology and Systemic Diseases, Hôpital François Mitterrand, Dijon, France
| | - Thibault Maillet
- Department of Internal Medicine and Clinical Immunology, Hôpital François Mitterrand, Dijon, France
| | - Mathilde Nouvier
- Department of Nephrology, Centre Hospitalier Lyon Sud, Lyon, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Paris, France
| | - Lara Meyer
- Department of Nephrology, Hôpital Européen Georges Pompidou, Paris, France
| | - Christian Lavigne
- Department of Internal Medicine-Clinical Immunology, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Alexis Régent
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Cécile-Audrey Durel
- Department of Internal Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Marc Fabre
- Department of Internal Medicine, Centre Hospitalier Pierre Oudot, Bourgouin, France
| | - Pierre Charles
- Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Quentin Raimbourg
- Department of Nephrology, Hôpital Bichat Claude Bernard, Paris, France
| | - Aurélia Lanteri
- Department of Internal Medicine-Infectious Diseases, Centre Hospitalier d'Antibes, Antibes, France
| | - Grégory Pugnet
- Department of Internal Medicine and Clinical Immunology, Hôpital Rangueil, Toulouse, France
| | - Frédéric Rivière
- Department of Pneumology, Hôpital d'Instruction des Armées Percy, Clamart, France
| | | | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, Hôpital Pitié Salpêtrière, Paris, France
| | - Guillaume Le Guenno
- Department of Internal Medicine, Hôpital d'Estaing, Clermont-Ferrand, France
| | - Pierre Jourdain
- Department of Nephrology, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Arsène Mekinian
- Department of Internal Medicine, Hôpital Saint-Antoine, Paris, France
| | - Romain Paule
- Department of Internal Medicine, Hôpital Foch, Suresnes, France
| | - Jérémie Dion
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Paul Legendre
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
- Department of Clinical Immunology, Centre Hospitalier du Mans, Le Mans, France
| | - Pascal Cohen
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Loïc Guillevin
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Xavier Puéchal
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, Hôpital Cochin, Paris, France
- National Reference Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
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Matias TB, Cordeiro RA, Duarte JA, de Jarry VM, Appenzeller S, Villarinho L, Reis F. Immune-Mediated Hypertrophic Pachymeningitis and its Mimickers: Magnetic Resonance Imaging Findings. Acad Radiol 2023; 30:2696-2706. [PMID: 36882352 DOI: 10.1016/j.acra.2023.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 01/08/2023] [Accepted: 01/13/2023] [Indexed: 03/08/2023]
Abstract
Hypertrophic pachymeningitis (HP) is a rare and chronic inflammatory disorder presenting as localized or diffuse thickening of the dura mater. It can be idiopathic or an unusual manifestation of immune-mediated, infectious, and neoplastic conditions. Although some cases may remain asymptomatic, HP can lead to progressive headaches, cranial nerve palsies, hydrocephalus, and other neurological complications, which makes its recognition a fundamental step for prompt treatment. Regarding the diagnosis workup, enhanced MRI is the most useful imaging method to evaluate dural thickening. This article addresses the MR imaging patterns of immune-mediated HP, including immunoglobulin G4-related disease, neurosarcoidosis, granulomatosis with polyangiitis, rheumatoid pachymeningitis, and idiopathic HP. The main infectious and neoplastic mimicking entities are also discussed with reference to conventional and advanced MR sequences.
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Affiliation(s)
- Thiago Bezerra Matias
- Department of Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Rafael Alves Cordeiro
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Juliana Avila Duarte
- Department of Internal Medicine, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Vinicius Menezes de Jarry
- Department of Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Simone Appenzeller
- Department of Orthopedics, Rheumatology and Traumatology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Luciano Villarinho
- Department of Radiology, Rhode Island Medical Imaging, Brown University, USA
| | - Fabiano Reis
- Department of Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil.
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Kattel T, Kc S, Schick J, Ng SJ, Lanade O. Fever of Unknown Origin in a Patient With Human Immunodeficiency Virus. Cureus 2023; 15:e49356. [PMID: 38143617 PMCID: PMC10749187 DOI: 10.7759/cureus.49356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2023] [Indexed: 12/26/2023] Open
Abstract
Fever of unknown origin (FUO) presents a diagnostic challenge, particularly in patients with human immunodeficiency virus (HIV) due to their immunocompromised state. We report a case of a 21-year-old male with HIV who presented with persistent fever and was found to have a positive proteinase-3 antibody, raising suspicion of granulomatosis with polyangiitis (GPA). The patient's symptoms, negative infectious workup, and elevated proteinase-3 levels prompted consideration of non-infectious etiologies. Despite the absence of renal involvement, corticosteroid therapy was initiated, leading to the resolution of fever. However, the false positive association of proteinase-3 in HIV patients introduces uncertainty regarding the definitive diagnosis of GPA. A tissue biopsy would have provided further clarity, but it was not performed in this case. Our workup aligns more closely with a diagnosis of GPA, considering the patient's response to treatment and the absence of clinical deterioration. This case highlights the complexity of diagnosing non-infectious causes of FUO in HIV-infected individuals. It emphasizes the need for a multidisciplinary approach involving infectious disease specialists and rheumatologists to ensure accurate diagnosis and appropriate management.
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Affiliation(s)
- Trishna Kattel
- Internal Medicine, Crozer-Chester Medical Center, Upland, USA
| | - Shreeyanta Kc
- Internal Medicine, Crozer-Chester Medical Center, Upland, USA
| | - Jacob Schick
- Radiology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Sze Jia Ng
- Internal Medicine, Crozer-Chester Medical Center, Upland, USA
| | - Oladimeji Lanade
- Internal Medicine, University of Tennessee Health Science Center, Memphis, USA
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Ha JW, Park YB, Lee SW. Overlap Syndrome Consisting of Polymyositis/Dermatomyositis and ANCA-Associated Vasculitis According to the 2022 ACR/EULAR Criteria for Vasculitis: A Korean Single-Centre Study. J Clin Med 2023; 12:6748. [PMID: 37959218 PMCID: PMC10647414 DOI: 10.3390/jcm12216748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/21/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
The present study applied the 2022 American College of Rheumatology and European Alliance of Associations for Rheumatology classification criteria (the 2022 ACR/EULAR criteria) for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) to ANCA-positive patients with polymyositis (PM)/dermatomyositis (DM). Also, this study investigated how many patients could be diagnosed with overlap syndrome consisting of PM/DM and AAV. Twelve ANCA-positive patients with PM/DM were included and analysed in this study. The 2022 ACR/EULAR classification criteria for microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA), and eosinophilic GPA (EGPA) are scoring systems, and when a total score is over five in cases of MPA and GPA and over six in cases of EGPA, AAV can be classified. The median age of 12 ANCA-positive patients (six with PM and six with DM) was 54.0 years and one patient (8.3%) was male. Of the 12 ANCA-positive patients with PM/DM, 11 had myeloperoxidase (MPO)-ANCA (or perinuclear [P]-ANCA) and the remaining one had proteinase 3 (PR3)-ANCA (or cytoplasmic [C]-ANCA). Nine (75.5%) and one (8.3%) ANCA-positive patients with PM/DM were diagnosed with overlap syndrome consisting of PM/DM and MPA and overlap syndrome consisting of PM/DM and GPA, respectively. The main contributors to the classification of MPA and GPA were interstitial lung disease and renal vasculitis, along with ANCA positivity, respectively. In conclusion, this study was the first to demonstrate that 83.3% of them could be diagnosed with overlap syndrome consisting of PM/DM and AAV according to the 2022 ACR/EULAR criteria for AAV.
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Affiliation(s)
- Jang Woo Ha
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (J.W.H.); (Y.-B.P.)
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (J.W.H.); (Y.-B.P.)
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (J.W.H.); (Y.-B.P.)
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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67
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Marozzi MS, Vacca A, Desantis V, Panebianco T, Catena C, Brosolo G, Noviello S, Cirulli A, Solimando AG, Sechi LA, Cicco S, Ria R. Changes in Lipids in Granulomatosis with Polyangiitis Relates to Glucocorticoids and History of Hypertension. Metabolites 2023; 13:1053. [PMID: 37887378 PMCID: PMC10608943 DOI: 10.3390/metabo13101053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/20/2023] [Accepted: 10/03/2023] [Indexed: 10/28/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA) is an ANCA-associated small-vessel vasculitis. Vessel wall inflammation induces multiple vascular damages, leading to accelerated atherosclerosis. Metabolic profile and cardiovascular risk are somewhat understood in GPA patients. Cardiovascular atherosclerotic disease (ASCVD) may represent a risk for outcomes. Our purpose is to evaluate ASCVD risk in GPA patients. Thirty-six patients received GPA diagnosis (T0) and were evaluated after 1 (T1) and 2 (T2) years follow-up. All patients were treated with high-dose glucocorticoid, one-year tapered, along with immunosuppressants. Total cholesterol significantly increased in T1 vs. T0 and T2. LDL exhibited the same trend, while triglycerides increased in both T1 and T2 vs. T0. No difference was found in HDL. A significant hsCRP decrease was detected at T1 and T2 vs. T0, but not between T2 and T1. Moreover, we found a significant reduction in ESR at T2 compared with T1 and T0 and at T1 compared to T0. Hypertensive patients presented a pronounced increase in lipids, while inflammation reduced slowly compared to normotensives. Our data suggest that the increase in cholesterol and LDL in T1 is a consequence of glucocorticoids. These data can be useful in the evaluation of both CV diseases and lipid metabolism, which are closely related to vessel inflammation.
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Affiliation(s)
- Marialuisa Sveva Marozzi
- Unit of Internal Medicine “Guido Baccelli”, Department of Precision and Regenerative Medicine and Ionian Area—(DiMePRe-J), University of Bari Aldo Moro, 70124 Bari, BA, Italy
- Unit of Hypertension “A.M. Pirrelli”, Department of Precision and Regenerative Medicine and Ionian Area—(DiMePRe-J), University of Bari Aldo Moro, 70124 Bari, BA, Italy
| | - Antonio Vacca
- Clinica Medica, Department of Medicine, University of Udine, 33100 Udine, UD, Italy
| | - Vanessa Desantis
- Unit of Internal Medicine “Guido Baccelli”, Department of Precision and Regenerative Medicine and Ionian Area—(DiMePRe-J), University of Bari Aldo Moro, 70124 Bari, BA, Italy
- Pharmacology Section, Department of Precision and Regenerative Medicine and Ionian Area—(DiMePRe-J), University of Bari Aldo Moro, 70124 Bari, BA, Italy
| | - Teresa Panebianco
- Unit of Internal Medicine “Guido Baccelli”, Department of Precision and Regenerative Medicine and Ionian Area—(DiMePRe-J), University of Bari Aldo Moro, 70124 Bari, BA, Italy
| | - Cristiana Catena
- Clinica Medica, Department of Medicine, University of Udine, 33100 Udine, UD, Italy
| | - Gabriele Brosolo
- Clinica Medica, Department of Medicine, University of Udine, 33100 Udine, UD, Italy
| | - Silvia Noviello
- Unit of Internal Medicine “Guido Baccelli”, Department of Precision and Regenerative Medicine and Ionian Area—(DiMePRe-J), University of Bari Aldo Moro, 70124 Bari, BA, Italy
| | - Anna Cirulli
- Unit of Internal Medicine “Guido Baccelli”, Department of Precision and Regenerative Medicine and Ionian Area—(DiMePRe-J), University of Bari Aldo Moro, 70124 Bari, BA, Italy
| | - Antonio Giovanni Solimando
- Unit of Internal Medicine “Guido Baccelli”, Department of Precision and Regenerative Medicine and Ionian Area—(DiMePRe-J), University of Bari Aldo Moro, 70124 Bari, BA, Italy
| | | | - Sebastiano Cicco
- Unit of Internal Medicine “Guido Baccelli”, Department of Precision and Regenerative Medicine and Ionian Area—(DiMePRe-J), University of Bari Aldo Moro, 70124 Bari, BA, Italy
- Unit of Hypertension “A.M. Pirrelli”, Department of Precision and Regenerative Medicine and Ionian Area—(DiMePRe-J), University of Bari Aldo Moro, 70124 Bari, BA, Italy
| | - Roberto Ria
- Unit of Internal Medicine “Guido Baccelli”, Department of Precision and Regenerative Medicine and Ionian Area—(DiMePRe-J), University of Bari Aldo Moro, 70124 Bari, BA, Italy
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Yoon T, Ha JW, Ko E, Song JJ, Park YB, Ahn SS, Lee SW. Vasculitis Activity-Predicting Ability of IL-12 Family Cytokines in Patients with Microscopic Polyangiitis and Granulomatosis with Polyangiitis. Yonsei Med J 2023; 64:604-611. [PMID: 37727919 PMCID: PMC10522880 DOI: 10.3349/ymj.2023.0226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/07/2023] [Accepted: 07/09/2023] [Indexed: 09/21/2023] Open
Abstract
PURPOSE The present study investigated and compared the antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) activity-predicting ability of the serum concentrations of the four interleukin (IL)-12 family cytokines including IL-23, IL-27, IL-35, and IL-39 in patients with microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA). MATERIALS AND METHODS The present study included 70 patients with MPA and GPA. Clinical and laboratory data, particularly Birmingham Vasculitis Activity Score (BVAS), at the time of blood collection were obtained. The serum concentrations of IL-23, IL-27, IL-35, and IL-37 were measured using sera stored at -80℃. Patients were divided into two groups: the upper half of BVAS (BVAS ≥12) and the lower half of BVAS (BVAS <12). RESULTS The serum concentrations of IL-23 and IL-27 reflected AAV activity. Patients with the upper half of BVAS exhibited significantly higher serum concentrations of IL-23 and IL-27 than those without. Patients with the serum concentrations of IL-23 ≥132.1 pg/mL or IL-27 ≥684.7 pg/mL exhibited higher frequency and risk for the upper half of BVAS than those without [relative risks (RR) 5.143 and RR 4.091, respectively]. The serum concentrations of IL-27 were associated with age ≥65 years and proteinase 3-ANCA (or C-ANCA) negativity, whereas, those of IL-23 were associated with MPA. However, the serum concentrations of IL-35 and IL-39 were not useful in predicting AAV activity in this study. CONCLUSION The present study is the first to demonstrate that among the various members of IL-12 family cytokines, the serum concentrations of IL-23 and IL-27 possess AAV activity-predicting ability.
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Affiliation(s)
- Taejun Yoon
- Department of Medical Science, BK2 Plus Project, Yonsei University College of Medicine, Seoul, Korea
| | - Jang Woo Ha
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eunhee Ko
- Department of Medical Science, BK2 Plus Project, Yonsei University College of Medicine, Seoul, Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Soo Ahn
- Division of Rheumatology, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea.
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Korea.
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Yoon T, Ha JW, Pyo JY, Song JJ, Park YB, Ahn SS, Lee SW. Soluble triggering receptor expressed on myeloid cell-1 reflects the cross-sectional activity of microscopic polyangiitis and granulomatosis with polyangiitis. Heliyon 2023; 9:e20881. [PMID: 37886760 PMCID: PMC10597820 DOI: 10.1016/j.heliyon.2023.e20881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023] Open
Abstract
Objectives We investigated whether soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) reflects cross-sectional activity of microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA). Methods Forty-seven MPA and 32 GPA patients with well-documented clinical records and stored sera were enrolled. sTREM-1 levels were evaluated using Magnetic Luminex® assay, and disease activity was assessed using Birmingham vasculitis activity score (BVAS). Patients were divided into two groups according to the upper and lower halves of BVAS. Receiver operator characteristic (ROC) curve analysis was used to identify cut-off for determining upper half of BVAS. Linear and binary logistic regression was performed to evaluate the association between sTREM-1 and disease activity and status. Results The median age of patients was 67.0 years, and 58.2 % were women. The median BVAS and sTREM-1 were 12.0 and 467.1 pg/mL. sTREM-1 was significantly correlated with BVAS along with five-factor score, Short-Form 36-Item Health Surveys, and C-reactive protein. In multivariable linear regression analysis, erythrocyte sedimentation rate (standardised β 0.241), and sTREM-1 (standardised β 0.288) were correlated with BVAS. ROC analysis revealed that the cut-off of sTREM-1 for the upper half of BVAS was 474.1 pg/mL. MPA and GPA patients with sTREM-1 ≥474.1 pg/mL exhibited a significantly higher risk for the upper half of BVAS than those without (relative risk 5.932). Multivariable logistic regression analysis demonstrated sTREM-1 ≥474.1 pg/mL (odds ratio 5.662) was associated with the upper half of BVAS. Conclusion sTREM-1 reflects the activity of MPA and GPA, suggesting its role as a potential biomarker for assessing disease severity.
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Affiliation(s)
- Taejun Yoon
- Department of Medical Science, BK21 Plus Project, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Jang Woo Ha
- Division of Rheumatology, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Republic of Korea
| | - Jung Yoon Pyo
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Soo Ahn
- Division of Rheumatology, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Republic of Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
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Houben E, de Groot PF, Vegting Y, Vos JMI, Nur E, Hilhorst ML, Hak AE(L, Kwakernaak AJ. Not Everything Is as It Seems: A Case Series and Overview of Diseases Mimicking Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. J Clin Med 2023; 12:6144. [PMID: 37834788 PMCID: PMC10573599 DOI: 10.3390/jcm12196144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare heterogeneous disease in which treatment must be initiated early to prevent irreversible organ damage and death. There are several diseases that can mimic AAV, even in the presence of positive ANCA serology and/or histological evidence of vasculitis, as demonstrated in this case series. We reflect on the diagnostic approach of patients with AAV and provide an overview of AAV-mimicking diseases that can be considered in patients with atypical disease presentation or course.
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Affiliation(s)
- Eline Houben
- Department of Medicine, Division of Clinical Immunology and Allergy, Vasculitis Center of Expertise, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (E.H.)
| | - Pieter F. de Groot
- Department of Medicine, Division of Clinical Immunology and Allergy, Vasculitis Center of Expertise, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (E.H.)
| | - Yosta Vegting
- Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Medicine, Division of Nephrology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Josephine M. I. Vos
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Erfan Nur
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Marc L. Hilhorst
- Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Medicine, Division of Nephrology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - A. E. (Liesbeth) Hak
- Department of Medicine, Division of Clinical Immunology and Allergy, Vasculitis Center of Expertise, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (E.H.)
- Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Arjan J. Kwakernaak
- Department of Medicine, Division of Clinical Immunology and Allergy, Vasculitis Center of Expertise, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (E.H.)
- Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Medicine, Division of Nephrology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Watanabe R, Hashimoto M. Eosinophilic Granulomatosis with Polyangiitis: Latest Findings and Updated Treatment Recommendations. J Clin Med 2023; 12:5996. [PMID: 37762936 PMCID: PMC10532073 DOI: 10.3390/jcm12185996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) causes necrotizing vasculitis and eosinophil-rich granulomatous inflammation in small- to medium-sized vessels, resulting in multiple organ damage. EGPA is classified as an antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, with myeloperoxidase-ANCA detected in approximately one-third of the patients. Conventional treatment of EGPA relies on systemic glucocorticoids (GCs) in combination with cyclophosphamide when poor prognostic factors are present; however, the dilemma between disease control and drug-related adverse effects has long been a challenge. Recent studies have revealed that the genetic background, pathophysiology, and clinical manifestations differ between ANCA-positive and ANCA-negative patients; however, mepolizumab, an interleukin (IL)-5 inhibitor, is effective in both groups, suggesting that the IL-5-eosinophil axis is deeply involved in the pathogenesis of both ANCA-positive and ANCA-negative EGPA. This review summarizes the latest knowledge on the pathophysiology of EGPA and focuses on the roles of eosinophils and ANCA. We then introduce the current treatment recommendations and accumulated evidence for mepolizumab on EGPA. Based on current unmet clinical needs, we discuss potential future therapeutic strategies for EGPA.
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Affiliation(s)
- Ryu Watanabe
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
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Risal UP, Pangeni RP, Pandey R, Regmi PR, Karki A, Shah A. Unilateral diaphragmatic palsy and pleuropericarditis in a patient with granulomatosis with polyangiitis: a case report. J Med Case Rep 2023; 17:381. [PMID: 37670370 PMCID: PMC10481465 DOI: 10.1186/s13256-023-04105-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/27/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) is a rare small vessel vasculitis predominantly affecting upper and lower respiratory tract and kidneys. Unilateral diaphragmatic palsy could be a rare manifestation of GPA. Here we report a case of GPA in a 45-year-old male with unilateral diaphragmatic palsy with pleuropericarditis. CASE PRESENTATION We report a case of a 45-year-old Khas male who presented with acute onset chest pain and shortness of breath who had elevated right hemidiaphragm, bilateral pleural effusion and pericardial effusion who was later diagnosed as GPA. CONCLUSIONS GPA should be suspected in all patients with diaphragmatic palsy and pleuropericarditis with appropriate clinical and laboratory picture.
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Affiliation(s)
- Ujjwol Prasad Risal
- Department of Internal Medicine, Hospital for Advanced Medicine and Surgery, Dhumbarahi, Kathmandu, Nepal.
| | - Raju Prasad Pangeni
- Department of Pulmonology and Sleep Medicine, Hospital for Advanced Medicine and Surgery, Dhumbarahi, Kathmandu, Nepal
| | - Rakshya Pandey
- Department of Pulmonology and Sleep Medicine, Hospital for Advanced Medicine and Surgery, Dhumbarahi, Kathmandu, Nepal
| | - Pradeep Raj Regmi
- Hospital for Advanced Medicine and Surgery, Dhumbarahi, Kathmandu, Nepal
| | - Aditi Karki
- Perfect Diagnostic Centre, Samakhusi, Kathmandu, Nepal
| | - Avish Shah
- Everest Hospital, New Baneshwor, Kathmandu, Nepal
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Abstract
Vasculitis is a diverse group of disorders involving inflammation of the blood vessels. Approaching the diagnosis of vasculitis can be challenging, given the differing clinical presentation and organ manifestations. Often vasculitis is a diagnosis that is considered too late, given the heterogeneous presentation and various mimics. This article aims to provide physicians with a diagnostic approach to vasculitis.
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Affiliation(s)
- Kunal Mishra
- Division of Cardiovascular Medicine, University of Virginia, 1215 Lee Street, PO BOX- 100058, Charlottesville, VA 22902, USA
| | - Randy K Ramcharitar
- Division of Cardiovascular Medicine, University of Virginia, 1215 Lee Street, PO BOX- 100058, Charlottesville, VA 22902, USA
| | - Aditya M Sharma
- Division of Cardiovascular Medicine, University of Virginia, 1215 Lee Street, PO BOX- 100058, Charlottesville, VA 22902, USA.
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Watanabe R, Oshima M, Nishioka N, Sada KE, Nagasaka K, Akiyama M, Ando T, Higuchi T, Inoue Y, Kida T, Mutoh T, Nakabayashi A, Onishi A, Sakai R, Waki D, Yamada Y, Yajima N, Tamura N, Kaname S, Harigai M. Systematic review and meta-analysis for 2023 clinical practice guidelines of the Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis for the management of ANCA-associated vasculitis. Mod Rheumatol 2023; 33:982-989. [PMID: 36112482 DOI: 10.1093/mr/roac114] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/24/2022] [Indexed: 08/27/2023]
Abstract
OBJECTIVES The objective of this study is to provide evidence for the revision of clinical practice guidelines for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis by the Japan Research Committee for Intractable Vasculitis. METHODS PubMed, CENTRAL, and the Japan Medical Abstracts Society databases were searched for articles published between 2015 and 2020 to update the systematic review for existing clinical questions, while PubMed, CENTRAL, EMBASE, and the Japan Medical Abstracts Society were searched for articles published between 2000 and 2020 to conduct a systematic review for newly developed clinical questions. The certainty of evidence was assessed with the GRADE approach. RESULTS For remission induction, when used in conjunction with cyclophosphamide or rituximab, reduced-dose glucocorticoid lowered the risk of serious adverse events compared to standard-dose glucocorticoid. Avacopan improved sustained remission at 12 months compared to high-dose glucocorticoid. Addition of plasma exchange to remission induction therapy did not reduce the risk of death, end-stage kidney disease, or relapse. For remission maintenance, rituximab reduced the risk of relapse compared to azathioprine. Long-term rituximab or azathioprine reduced the risk of relapse compared to short-term rituximab or azathioprine, respectively. CONCLUSIONS This systematic review provided evidence required to develop the 2023 clinical practice guideline for the management of ANCA-associated vasculitis.
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Affiliation(s)
- Ryu Watanabe
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Megumi Oshima
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Japan
| | - Norihiro Nishioka
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Graduate School of Medicine, Okayama University, Okayama, Japan
- Department of Clinical Epidemiology, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Kenji Nagasaka
- Department of Rheumatology, Ome Municipal General Hospital, Ome, Japan
- Department of Rheumatology and Medicine, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Mitsuhiro Akiyama
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Taiki Ando
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Tomoaki Higuchi
- Division of Multidisciplinary Management of Rheumatic Diseases, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yoshino Inoue
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Takashi Kida
- Department of Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomoyuki Mutoh
- Department of Rheumatology, Osaki Citizen Hospital, Osaki, Japan
- Department of Rheumatology, Tohoku University Hospital, Sendai, Japan
| | - Akihiko Nakabayashi
- Department of Rheumatology and Allergology, National Hospital Organization Osaka Minami Medical Center, Osaka, Japan
| | - Akira Onishi
- Department of Advanced Medicine for Rheumatic diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryota Sakai
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Daisuke Waki
- Department of Endocrinology and Rheumatology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yosuke Yamada
- Department of Nephrology, Shinshu University School of Medicine, Nagano, Japan
| | - Nobuyuki Yajima
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Shinya Kaname
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Mitaka, Japan
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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75
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Heras Benito M. [Complement in vasculitis associated with anti-neutrophil cytoplasm antibodies with renal involvement: pathogenic, prognostic and therapeutic implications]. Med Clin (Barc) 2023; 161:160-165. [PMID: 37236835 DOI: 10.1016/j.medcli.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/22/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023]
Abstract
Antineutrophil cytoplasmic antibody-associated vasculitides are primary vasculitides that affect small vessels in various organs, including the kidney. Renal involvement is characterized by the presence of glomerulonephritis with crescents and necrosis in light microscopy and a pauci-immune pattern in immunofluorescence. The participation of complement in the pathogenesis of these entities has been valued in recent years, initially in animal models and later in studies in humans, by demonstrating the presence of fragments of the alternative complement pathway, in plasma and urine, together with complement deposits in glomeruli and small vessels of patients affected by antineutrophil cytoplasmic antibody vasculitis. The presence of complement in these entities confers a worse general and renal prognosis.
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Affiliation(s)
- Manuel Heras Benito
- Servicio de Nefrología, Hospital Universitario de Salamanca, Salamanca, España.
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76
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Sims CA, Bermas BL, Clowse MEB. Vasculitis and Pregnancy: Disease State and Management. Rheum Dis Clin North Am 2023; 49:679-694. [PMID: 37331740 DOI: 10.1016/j.rdc.2023.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Family planning in women with vasculitis requires an interdisciplinary approach. This article summarizes recommendations and guidance for each phase of family planning in persons with vasculitis including preconception counseling, birth control, pregnancy, and breastfeeding. Pregnancy complications are presented by category of vasculitis with accompanying diagnostic and therapeutic recommendations. Birth control and assisted reproductive technology options are reviewed with special considerations for women who are high risk or have a history of blood clots. This article can be used as a clinical reference for reproductive discussions in all patients with vasculitis.
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Affiliation(s)
- Catherine A Sims
- Division of Rheumatology, Duke University, 1021 Red Hat Lane, Durham, NC 27713, USA.
| | - Bonnie L Bermas
- University of Texas Southwestern, 2001 Inwood Road, Dallas, TX 75235, USA
| | - Megan E B Clowse
- Division of Rheumatology & Immunology, Duke University, 40 Duke Medicine Circle Clinic 1J, Durham, NC 27713, USA
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77
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Chen J, Meng T, Xu J, Ooi JD, Eggenhuizen PJ, Liu W, Li F, Wu X, Sun J, Zhang H, Zhou YO, Luo H, Xiao X, Pei Y, Li W, Zhong Y. Development of a radiomics nomogram to predict the treatment resistance of Chinese MPO-AAV patients with lung involvement: a two-center study. Front Immunol 2023; 14:1084299. [PMID: 37503353 PMCID: PMC10369051 DOI: 10.3389/fimmu.2023.1084299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 06/19/2023] [Indexed: 07/29/2023] Open
Abstract
Background Previous studies from our group and other investigators have shown that lung involvement is one of the independent predictors for treatment resistance in patients with myeloperoxidase (MPO)-anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (MPO-AAV). However, it is unclear which image features of lung involvement can predict the therapeutic response in MPO-AAV patients, which is vital in decision-making for these patients. Our aim was to develop and validate a radiomics nomogram to predict treatment resistance of Chinese MPO-AAV patients based on low-dose multiple slices computed tomography (MSCT) of the involved lung with cohorts from two centers. Methods A total of 151 MPO-AAV patients with lung involvement (MPO-AAV-LI) from two centers were enrolled. Two different models (Model 1: radiomics signature; Model 2: radiomics nomogram) were built based on the clinical and MSCT data to predict the treatment resistance of MPO-AAV with lung involvement in training and test cohorts. The performance of the models was assessed using the area under the curve (AUC). The better model was further validated. A nomogram was constructed and evaluated by DCA and calibration curves, which further tested in all enrolled data and compared with the other model. Results Model 2 had a higher predicting ability than Model 1 both in training (AUC: 0.948 vs. 0.824; p = 0.039) and test cohorts (AUC: 0.913 vs. 0.898; p = 0.043). As a better model, Model 2 obtained an excellent predictive performance (AUC: 0.929; 95% CI: 0.827-1.000) in the validation cohort. The DCA curve demonstrated that Model 2 was clinically feasible. The calibration curves of Model 2 closely aligned with the true treatment resistance rate in the training (p = 0.28) and test sets (p = 0.70). In addition, the predictive performance of Model 2 (AUC: 0.929; 95% CI: 0.875-0.964) was superior to Model 1 (AUC: 0.862; 95% CI: 0.796-0.913) and serum creatinine (AUC: 0.867; 95% CI: 0.802-0.917) in all patients (all p< 0.05). Conclusion The radiomics nomogram (Model 2) is a useful, non-invasive tool for predicting the treatment resistance of MPO-AAV patients with lung involvement, which might aid in individualizing treatment decisions.
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Affiliation(s)
- Juan Chen
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ting Meng
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jia Xu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Joshua D. Ooi
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Centre for Inflammatory Diseases, Monash University, Clayton, VIC, Australia
| | | | - Wenguang Liu
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Fang Li
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xueqin Wu
- Department of Nephrology, The third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jian Sun
- Department of Nephrology, The third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hao Zhang
- Department of Nephrology, The third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ya-Ou Zhou
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, China
| | - Hui Luo
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiangcheng Xiao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yigang Pei
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wenzheng Li
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yong Zhong
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, Hunan, China
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Kuang Q, He X, Jia L, Zhang Z, Gui C, Gao C, Xia Z. Case report: A pediatric case of MPO-ANCA-associated granulomatosis with polyangiitis superimposed on post-streptococcal acute glomerulonephritis. Front Pediatr 2023; 11:1148132. [PMID: 37492611 PMCID: PMC10364118 DOI: 10.3389/fped.2023.1148132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/23/2023] [Indexed: 07/27/2023] Open
Abstract
An eight-year-old girl was admitted with vomiting, gross hematuria, and progressive renal dysfunction. A renal biopsy revealed endocapillary proliferative glomerulopathy and crescent formation. Immunofluorescence staining revealed diffuse granular deposits of IgG and C3. Post-streptococcal acute glomerulonephritis (PSAGN) was suspected, based on the elevated anti-streptolysin O levels, decreased serum C3 concentrations, and histologic findings. The myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) test was positive, and the young patient gradually developed palisaded neutrophilic and granulomatous dermatitis (PNGD), orbital and paranasal sinus granulomatous neoplasms, along with intermittent nose, head, and orbital pain. Finally, she was diagnosed with the rare MPO-ANCA-associated granulomatosis with polyangiitis (GPA) superimposed on PSAGN. The patient was treated with aggressive renal replacement therapy, methylprednisolone pulse therapy, and intravenous pulse cyclophosphamide; her renal function normalized, and her pain symptoms improved.
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Andrade MM, Fernandes M, Freire S, Cruz D. Limited Antineutrophil Cytoplasmic Antibodies (ANCA)-Negative Granulomatosis With Polyangiitis: Successful Response to Rituximab. Cureus 2023; 15:e41826. [PMID: 37575714 PMCID: PMC10423013 DOI: 10.7759/cureus.41826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA), a systemic vasculitis, is commonly characterized by the presence of antineutrophil cytoplasmic antibodies (ANCA). However, a subset of patients with limited disease may exhibit ANCA negativity. In this article, we report the case of a 40-year-old female diagnosed with GPA with intolerance to methotrexate titration and glucocorticoid therapy, leading to the initiation of rituximab treatment. Subsequently, the patient exhibited sustained clinical, laboratory, and radiological improvement. The identification of limited GPA has important therapeutic implications as the effectiveness of the medical treatment in ANCA-negative GPA may differ. Rituximab has emerged as an optimal treatment, irrespective of ANCA status, offering prolonged responses and a favorable tolerance profile in these patients.
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Affiliation(s)
| | - Manuel Fernandes
- Pulmonology, Hospital de Cascais, Dr. José de Almeida, Cascais, PRT
| | - Sara Freire
- Internal Medicine, Hospital de Cascais, Dr. José de Almeida, Cascais, PRT
| | - Diogo Cruz
- Internal Medicine, Hospital de Cascais, Dr. José de Almeida, Cascais, PRT
- Clínica Universitária de Medicina I, Faculdade de Medicina da Universidade de Lisboa, Lisboa, PRT
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Ha JW, Ahn SS, Song JJ, Park YB, Lee SW. Total Globulin Fraction at Diagnosis Could Forecast All-Cause Mortality during the Disease Course in Patients with Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. J Clin Med 2023; 12:4170. [PMID: 37373863 DOI: 10.3390/jcm12124170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023] Open
Abstract
Total globulin fraction (TGF) is calculated by subtracting serum albumin levels from serum total protein levels. The present study examined whether TGF at diagnosis could forecast all-cause mortality during the disease course in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). The present study included 283 patients with AAV. The variables at AAV diagnosis such as demographic data, AAV-specific data including the Birmingham vasculitis activity score (BVAS), five-factor score (FFS), and laboratory data including ANCA, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were collected. The number of deceased patients during the follow-up duration based on all-cause mortality was counted. The median age of the 283 AAV patients was 60 years, and 35.7% were men. ANCAs were detected in 228 patients, and the median TGF was 2.9. A total of 39 patients (13.8%) died within a median follow-up duration of 46.9 months. TGF at AAV diagnosis was significantly correlated with ESR and CRP rather than AAV activity. Patients with ANCA positivity exhibited a significantly higher median TGF at AAV diagnosis than those without. Patients with TGF ≥ 3.1 g/dL at AAV diagnosis exhibited a significantly lower cumulative survival rate than those without. Furthermore, in the multivariable Cox hazards model analysis, TGF ≥ 3.1 g/dL (hazard ratio 2.611) was independently associated with all-cause mortality, along with age, male sex, and body mass index. The present study is the first to demonstrate that TGF at AAV diagnosis can forecast all-cause mortality during the disease course in AAV patients.
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Affiliation(s)
- Jang-Woo Ha
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Sung-Soo Ahn
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jason-Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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Valeyre D, Brauner M, Bernaudin JF, Carbonnelle E, Duchemann B, Rotenberg C, Berger I, Martin A, Nunes H, Naccache JM, Jeny F. Differential diagnosis of pulmonary sarcoidosis: a review. Front Med (Lausanne) 2023; 10:1150751. [PMID: 37250639 PMCID: PMC10213276 DOI: 10.3389/fmed.2023.1150751] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Diagnosing pulmonary sarcoidosis raises challenges due to both the absence of a specific diagnostic criterion and the varied presentations capable of mimicking many other conditions. The aim of this review is to help non-sarcoidosis experts establish optimal differential-diagnosis strategies tailored to each situation. Alternative granulomatous diseases that must be ruled out include infections (notably tuberculosis, nontuberculous mycobacterial infections, and histoplasmosis), chronic beryllium disease, hypersensitivity pneumonitis, granulomatous talcosis, drug-induced granulomatosis (notably due to TNF-a antagonists, immune checkpoint inhibitors, targeted therapies, and interferons), immune deficiencies, genetic disorders (Blau syndrome), Crohn's disease, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, and malignancy-associated granulomatosis. Ruling out lymphoproliferative disorders may also be very challenging before obtaining typical biopsy specimen. The first step is an assessment of epidemiological factors, notably the incidence of sarcoidosis and of alternative diagnoses; exposure to risk factors (e.g., infectious, occupational, and environmental agents); and exposure to drugs taken for therapeutic or recreational purposes. The clinical history, physical examination and, above all, chest computed tomography indicate which differential diagnoses are most likely, thereby guiding the choice of subsequent investigations (e.g., microbiological investigations, lymphocyte proliferation tests with metals, autoantibody assays, and genetic tests). The goal is to rule out all diagnoses other than sarcoidosis that are consistent with the clinical situation. Chest computed tomography findings, from common to rare and from typical to atypical, are described for sarcoidosis and the alternatives. The pathology of granulomas and associated lesions is discussed and diagnostically helpful stains specified. In some patients, the definite diagnosis may require the continuous gathering of information during follow-up. Diseases that often closely mimic sarcoidosis include chronic beryllium disease and drug-induced granulomatosis. Tuberculosis rarely resembles sarcoidosis but is a leading differential diagnosis in regions of high tuberculosis endemicity.
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Affiliation(s)
- Dominique Valeyre
- Pulmonology Department, Groupe Hospitalier Paris Saint Joseph, Paris, France
- INSERM UMR 1272, Sorbonne University Paris-Nord, Paris, France
| | - Michel Brauner
- Radiology Department, Avicenne University Hospital, Bobigny, France
| | - Jean-François Bernaudin
- INSERM UMR 1272, Sorbonne University Paris-Nord, Paris, France
- Faculté de Médecine, Sorbonne University Paris, Paris, France
| | | | - Boris Duchemann
- INSERM UMR 1272, Sorbonne University Paris-Nord, Paris, France
- Thoracic and Oncology Department, Avicenne University Hospital, Bobigny, France
| | - Cécile Rotenberg
- INSERM UMR 1272, Sorbonne University Paris-Nord, Paris, France
- Pulmonology Department, Avicenne University Hospital, Bobigny, France
| | - Ingrid Berger
- Pulmonology Department, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Antoine Martin
- Pathology Department, Avicenne University Hospital, Bobigny, France
| | - Hilario Nunes
- INSERM UMR 1272, Sorbonne University Paris-Nord, Paris, France
- Pulmonology Department, Avicenne University Hospital, Bobigny, France
| | - Jean-Marc Naccache
- Pulmonology Department, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Florence Jeny
- INSERM UMR 1272, Sorbonne University Paris-Nord, Paris, France
- Pulmonology Department, Avicenne University Hospital, Bobigny, France
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Hankard A, Puéchal X, Martin Silva N, Deshayes S, Lorcy N, Le Gallou T, Carron PL, Daugas E, Kaplanski G, Boutemy J, Maigné G, Galimard C, Terrier B, Aouba A, de Boysson H. Characteristics of ANCA-associated vasculitis with aneurysms: Case series and review of the literature. Autoimmun Rev 2023; 22:103293. [PMID: 36787809 DOI: 10.1016/j.autrev.2023.103293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION ANCA-associated vasculitis (AAV) is an exceptional cause of small and large vascular aneurysms. Here, we present the phenotypic characteristics of patients with AAV associated with the presence of aneurysms. METHODS We conducted a retrospective multicenter study and a systematic review of the literature. Only AAV patients with positive ANCA results and > 1 aneurysm(s) were enrolled. Patients were recruited through a call of observations among the French Vasculitis Study Group (FVSG) and the French Internal Medicine Network. Patients with aneurysm rupture were compared to those without. RESULTS We enrolled 51 patients in the cohort, including 31 (67%) with granulomatosis with polyangiitis. The median Birmingham Vasculitis Activity Score was 18 [6-41]. A total of 92 aneurysms were noted, 74% of which involved medium-sized arteries, particularly the renal artery. During a follow-up of 24 [6-56] months, 22 (43%) patients experienced aneurysmal rupture, 91% of which involved medium-sized vessels. Patients with aneurysmal rupture showed significantly more pulmonary infiltrates and higher creatinine levels at baseline than patients without rupture. Initial treatments did not differ between the two groups. Ten (20%) patients died during the follow-up, including three from an aneurysmal rupture. CONCLUSION Aneurysms were more frequently observed in GPA patients and predominantly affected medium-sized vessels, especially the renal arteries. The risk of rupture was high and occurred in >40% of patients. Because of their increased mortality, further studies are required to better manage this subset of patients.
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Affiliation(s)
- Antoine Hankard
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France.
| | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Centre, Université Paris Cité, Paris, France
| | - Nicolas Martin Silva
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Samuel Deshayes
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Nolwenn Lorcy
- Department of Nephrology, Rennes University Hospital, Rennes, France
| | - Thomas Le Gallou
- Department of Internal Medicine, Rennes University Hospital, South Hospital, Rennes, France
| | | | - Eric Daugas
- Department of Nephrology, Bichat-Claude-Bernard Hospital, University Hospital Center, APHP, Paris, France
| | - Gilles Kaplanski
- Department of Internal Medicine, La Conception Hospital, University Hospital Center, APHM, Marseille, France
| | - Jonathan Boutemy
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Gwénola Maigné
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Caroline Galimard
- Department of Infectious Disease Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Centre, Université Paris Cité, Paris, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France; Université de Caen Normandie, Caen, France
| | - Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France; Université de Caen Normandie, Caen, France
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Qudsiya Z, Viqas Z, Baker DL. A Runny Nose Leads to a Rare Diagnosis: Chronic Sinusitis as a Sole Manifestation of Limited Granulomatosis With Polyangiitis. Cureus 2023; 15:e39203. [PMID: 37337503 PMCID: PMC10276886 DOI: 10.7759/cureus.39203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/21/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA) is an antineutrophil cytoplasmic antibody (ANCA)-associated necrotizing vasculitis of small to medium-sized blood vessels. The typical presentation is the classic triad of upper airway, pulmonary, and renal involvement. However, it can rarely present with the involvement of a single organ system known as limited granulomatosis with polyangiitis. We present a case of a 53-year-old male with chronic rhinosinusitis as the only manifestation of limited GPA. The diagnosis was established incidentally based on biopsy findings from the paranasal sinuses obtained during functional endoscopic sinus surgery. Subsequent testing revealed a positive cytoplasmic antineutrophilic antibody. No evidence of systemic involvement was noted. Prednisone and azathioprine were initiated leading to significant improvement. Although upper respiratory tract involvement is common in GPA, it is rare for the condition to be limited to this organ system. Our case of limited GPA is distinct in that it represents a rare presentation of this already rare disease.
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Affiliation(s)
- Zainab Qudsiya
- Internal Medicine, St. Luke's Hospital, Chesterfield, USA
| | - Zaineb Viqas
- Internal Medicine, ECU Health Medical Center, Greenville, USA
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84
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Patel A, Patel UM, Sojitra V. Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis (AAV) Masquerading As Mononeuritis Multiplex: A Case Report. Cureus 2023; 15:e38651. [PMID: 37288192 PMCID: PMC10242149 DOI: 10.7759/cureus.38651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 06/09/2023] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of disorders that causes severe small-vessel inflammation with systemic manifestations. There are three subtypes of AAV, namely granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic GPA (EGPA). The most commonly affected organs are the upper and lower respiratory tract and the kidneys with occasional and varied neurological manifestations. Here we report a case of a 61-year-old female who presented with a one-month history of numbness, paresthesia, and asymmetric distal weakness of both lower limbs without any bladder or bowel involvement. Similar complaints appeared in her upper limbs three days prior to admission. She also suffered from myalgia, arthralgia, reduced appetite, and lost 8-10 kg weight over the past six months. Her nerve conduction study (NCV) revealed asymmetrical, predominantly motor, mixed, axonal and demyelinating polyneuropathy affecting both lower limbs, which was suggestive of mononeuritis multiplex. After a detailed workup, she tested strongly positive for cytoplasmic ANCA (c-ANCA). Although there was no clinical involvement of the respiratory tract, a contrast-enhanced computed tomography scan of the thorax and abdomen showed multifocal subpleural and lung parenchymal soft tissue lesions and mediastinal and bilateral hilar lymphadenopathy suggestive of a granulomatous lesion. She was diagnosed with the GPA variant of ANCA-associated vasculitis. Remission induction was achieved with high-dose methylprednisolone and cyclophosphamide along with alternate-day cotrimoxazole. Remission was maintained with tapering doses of steroid and mycophenolate mofetil with a slow but sustained recovery. On follow-up after one year, she walked without support with mild residual burning paresthesia in both feet. This case highlights the fact that neurological symptoms can be the presenting manifestation of AAV, and clinicians should have a high level of suspicion for AAV in patients presenting with mononeuritis multiplex, especially after ruling out common causes. By considering such etiologies, it may be possible to diagnose the condition at an earlier stage and initiate treatment to prevent potential pulmonary or renal damage.
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Affiliation(s)
- Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Australia
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Azienda Ospedaliera Universitaria Meyer IRCCS, Firenze, Italy.
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, Firenze, Italy.
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86
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Cutaneous Deep Ulcerations as Initial Presentations of Granulomatosis with Polyangiitis: Two Case Reports and Differential Diagnosis. Medicina (B Aires) 2023; 59:medicina59030563. [PMID: 36984564 PMCID: PMC10057340 DOI: 10.3390/medicina59030563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 03/15/2023] Open
Abstract
Background: Granulomatosis with polyangiitis (GPA) is an antineutrophil-cytoplasmic-antibody (ANCA)-associated small-vessel vasculitis characterized by necrotizing granulomatous inflammation. Symptoms of skin involvement can appear in 30–50% of patients with GPA, and may present as the initial presentation. Case Presentation: We describe two patients who presented with multiple deep, large, nonhealing skin ulcers postoperatively with purulent drainage and fever. Both patients were diagnosed with GPA after an extensive evaluation, including histopathology. Infectious, connective tissue disease and malignant etiologies were excluded. Their cANCA and PR3-ANCA levels were positive. Patient 2 was diagnosed early and recovered well after treatment with corticosteroids and rituximab; however, Patient 1 had a poor prognosis due to a long disease course. Conclusions: Diseases with multiple deep, large skin ulcers and fever can be infectious or noninfectious. Atypical manifestations may lead to missed diagnosis and misdiagnosis. GPA may initially present in a localized form before progressing to a generalized disease. The two cases we have highlighted will prompt clinicians to nevertheless call for a low threshold for diagnosis.
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87
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Schimansky S, Cross G, Mulhearn B. Monocular Vision Loss in a Patient With Earache and Night Sweats. JAMA Ophthalmol 2023; 141:396-397. [PMID: 36892845 DOI: 10.1001/jamaophthalmol.2023.0174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
A 62-year-old patient with a history of painless vision loss in her right eye, right ear pain and fullness, discomfort over her frontal and maxillary sinuses, nasal congestion without discharge, drenching night sweats, cramps in her quadriceps, and weight loss presented to the ophthalmology department. Examination revealed normal tympanic membranes and a dry but otherwise normal nasal mucosa on flexible endoscopy. What would you do next?
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Affiliation(s)
- Sarah Schimansky
- Department of Ophthalmology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, United Kingdom
| | - Gary Cross
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, United Kingdom
| | - Ben Mulhearn
- Department of Rheumatology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, United Kingdom.,Department of Life Sciences, University of Bath, Claverton Down, Bath, United Kingdom
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88
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Kawasaki A, Sada KE, Kusumawati PA, Hirano F, Kobayashi S, Nagasaka K, Sugihara T, Ono N, Fujimoto T, Kusaoi M, Tamura N, Kusanagi Y, Itoh K, Sumida T, Yamagata K, Hashimoto H, Makino H, Arimura Y, Harigai M, Tsuchiya N. Association of HLA-class II alleles with risk of relapse in myeloperoxidase-antineutrophil cytoplasmic antibody positive vasculitis in the Japanese population. Front Immunol 2023; 14:1119064. [PMID: 36969218 PMCID: PMC10030796 DOI: 10.3389/fimmu.2023.1119064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/23/2023] [Indexed: 03/11/2023] Open
Abstract
BackgroundDisease relapse remains a major problem in the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). In European populations, HLA-DPB1*04:01 is associated with both susceptibility and relapse risk in proteinase 3-ANCA positive AAV. In a Japanese population, we previously reported an association between HLA-DRB1*09:01 and DQB1*03:03 with susceptibility to, and DRB1*13:02 with protection from, myeloperoxidase-ANCA positive AAV (MPO-AAV). Subsequently, the association of DQA1*03:02, which is in strong linkage disequilibrium with DRB1*09:01 and DQB1*03:03, with MPO-AAV susceptibility was reported in a Chinese population. However, an association between these alleles and risk of relapse has not yet been reported. Here, we examined whether HLA-class II is associated with the risk of relapse in MPO-AAV.MethodsFirst, the association of HLA-DQA1*03:02 with susceptibility to MPO-AAV and microscopic polyangiitis (MPA) and its relationship with previously reported DRB1*09:01 and DQB1*03:03 were examined in 440 Japanese patients and 779 healthy controls. Next, the association with risk of relapse was analyzed in 199 MPO-ANCA positive, PR3-ANCA negative patients enrolled in previously reported cohort studies on remission induction therapy. Uncorrected P values (Puncorr) were corrected for multiple comparisons in each analysis using the false discovery rate method.ResultsThe association of DQA1*03:02 with susceptibility to MPO-AAV and MPA was confirmed in a Japanese population (MPO-AAV: Puncorr=5.8x10-7, odds ratio [OR] 1.74, 95% confidence interval [CI] 1.40–2.16, MPA: Puncorr=1.1x10-5, OR 1.71, 95%CI 1.34–2.17). DQA1*03:02 was in strong linkage disequilibrium with DRB1*09:01 and DQB1*03:03, and the causal allele could not be determined using conditional logistic regression analysis. Relapse-free survival was shorter with nominal significance in carriers of DRB1*09:01 (Puncorr=0.049, Q=0.42, hazard ratio [HR]:1.87), DQA1*03:02 (Puncorr=0.020, Q=0.22, HR:2.11) and DQB1*03:03 (Puncorr=0.043, Q=0.48, HR:1.91) than in non-carriers in the log-rank test. Conversely, serine carriers at position 13 of HLA-DRβ1 (HLA-DRβ1_13S), including DRB1*13:02 carriers, showed longer relapse-free survival with nominal significance (Puncorr=0.010, Q=0.42, HR:0.31). By combining DQA1*03:02 and HLA-DRβ1_13S, a significant difference was detected between groups with the highest and lowest risk for relapse (Puncorr=0.0055, Q=0.033, HR:4.02).ConclusionHLA-class II is associated not only with susceptibility to MPO-AAV but also with risk of relapse in the Japanese population.
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Affiliation(s)
- Aya Kawasaki
- Molecular and Genetic Epidemiology Laboratory, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Master’s Program in Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
- *Correspondence: Aya Kawasaki, ; Naoyuki Tsuchiya,
| | - Ken-ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of Clinical Epidemiology, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Premita Ari Kusumawati
- Molecular and Genetic Epidemiology Laboratory, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Master’s Program in Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Fumio Hirano
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shigeto Kobayashi
- Department of Internal Medicine, Juntendo University Koshigaya Hospital, Saitama, Japan
| | - Kenji Nagasaka
- Department of Rheumatology, Ome Municipal General Hospital, Ome, Japan
| | - Takahiko Sugihara
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobuyuki Ono
- Department of Rheumatology, Saga University, Saga, Japan
| | - Takashi Fujimoto
- Department of General Medicine, Nara Medical University, Kashihara, Japan
| | - Makio Kusaoi
- Department of Internal Medicine and Rheumatology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yasuyoshi Kusanagi
- Division of Hematology and Rheumatology, Department of Internal Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Kenji Itoh
- Division of Hematology and Rheumatology, Department of Internal Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Takayuki Sumida
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | | | | | - Yoshihiro Arimura
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Mitaka, Japan
- Department of Internal Medicine, Kichijoji Asahi Hospital, Musashino, Japan
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women’s Medical University School of Medicine, Tokyo, Japan
| | - Naoyuki Tsuchiya
- Molecular and Genetic Epidemiology Laboratory, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Master’s Program in Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
- *Correspondence: Aya Kawasaki, ; Naoyuki Tsuchiya,
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Kronbichler A, Bond M, Dejaco C. Classification criteria for ANCA-associated vasculitis: one size does not fit all! Rheumatology (Oxford) 2023; 62:993-995. [PMID: 35904552 DOI: 10.1093/rheumatology/keac423] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Andreas Kronbichler
- Department of Medicine, University of Cambridge.,Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Milena Bond
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy.,Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
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90
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Ecclestone T, Watts RA. Classification and epidemiology of vasculitis: Emerging concepts. Best Pract Res Clin Rheumatol 2023; 37:101845. [PMID: 37468418 DOI: 10.1016/j.berh.2023.101845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/01/2023] [Accepted: 06/13/2023] [Indexed: 07/21/2023]
Abstract
The recent publication of the American College of Rheumatology (ACR)-European Alliance of Associations for Rheumatology (EULAR) classification criteria for large vessel vasculitis and anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) has provided modern criteria for the classification of these conditions, which incorporate contemporary methods of investigation and diagnosis. Further validation is required in independent cohorts, especially from populations that were not well represented in the development cohort. Studies of the occurrence of large vessel vasculitis report that Takayasu arteritis is a rare disease in most populations, and giant cell arteritis is the most common vasculitis in older populations. The incidence of AAV appears to have plateaued, but the prevalence is increasing as a result of lower mortality. The new classification criteria may affect the reported incidence and prevalence, and studies will be needed to confirm this. The impact of COVID-19 on the occurrence of the vasculitides is not completely known, but there is evidence of reduced occurrence of Kawasaki disease and IgA-associated vasculitis following lockdowns with reduced transmission of possible trigger infectious agents.
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91
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Polyangiitis overlap syndrome: a rare clinical entity. Rheumatol Int 2023; 43:537-543. [PMID: 36719484 PMCID: PMC9968253 DOI: 10.1007/s00296-023-05281-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/12/2023] [Indexed: 02/01/2023]
Abstract
Polyangiitis overlap syndrome is a rare clinical entity comprising patients with overlapping features of more than one vasculitis, usually eosinophilic granulomatosis with polyangiitis (EGPA) and granulomatosis with polyangiitis (GPA). Few cases of polyangiitis overlap syndrome have been described in the literature, mostly associated with c-ANCA, anti-proteinase (PR)-3 positivity, a protean clinical picture characterized by vasculitis, eosinophilia and eosinophilic infiltrates in tissues and a favorable response to steroids and immunosuppressant treatments. Herein, we present a case of a 66-year-old woman with nasal obstruction, external nose deformity, sensorineural hearing loss, peripheral blood eosinophilia, high titer anti-PR3 antibodies and lung involvement. Nasal septum biopsies showed inflammatory infiltrate with eosinophilic component; histopathology of the lung demonstrated necrotizing granulomas associated with inflammatory infiltrate composed of numerous neutrophils and some eosinophils. The patient was diagnosed with polyangiitis overlap syndrome and successfully treated with cyclophosphamide. Recognizing this entity is fundamental given the distinct clinical phenotype and outcomes to therapy in the complex scenario of ANCA-associated vasculitides.
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Egorova ON, Kharlamova EN, Tarasova GM. Differential diagnosis of a local form of granulomatosis with polyangiitis: nasal cavity and paranasal sinuses lesions (part 1). MODERN RHEUMATOLOGY JOURNAL 2023. [DOI: 10.14412/1996-7012-2023-1-7-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Granulomatosis with polyangiitis (GPA) is a primary vasculitis associated with antineutrophil cytoplasmic antibodies, characterized by necrotizing vasculitis with predominant involvement of small vessels of various localizations and necrotizing granulomatous inflammation with multiple clinical manifestations. GPA remains one of the most severe systemic vasculitis with unfavorable prognosis. When analyzing the course of the disease, there are two variants of GPA, local (with lesions of the upper respiratory tract, URT, organs of vision and hearing) and generalized (with lesions of the URT, organs of vision and hearing in combination with the lungs and/or kidneys, gastrointestinal tract, nervous systems, skin involvement).The article discusses the differential diagnosis of the disease with the nasal cavity and paranasal sinuses lesions onset, which requires an interdisciplinary approach and interaction of doctors of different specialties.
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93
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Rimmer J, Lund VJ. Non-Eosinophilic Granulomatous Disease and the Unified Airway. Otolaryngol Clin North Am 2023; 56:83-95. [DOI: 10.1016/j.otc.2022.09.006] [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]
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94
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Coexistence of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and IgA nephropathy. Immunol Res 2023; 71:1-14. [PMID: 36227529 DOI: 10.1007/s12026-022-09322-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/14/2022] [Indexed: 01/20/2023]
Abstract
Co-occurrence of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and IgA nephropathy (IgAN) is extremely uncommon. To date, only a few case reports have described such patients. Here, we describe the clinical presentation, pathologic features, treatment response, and outcome data of five patients with the rare form of co-existing AAV and IgAN and compared the characteristics of these patients to AAV patients with pauci-immune glomerulonephritis (n = 10) and IgAN patients (n = 10) that were selected as controls by stratified random sampling. In addition, we summarize all the previously reported cases of AAV and IgAN. In total, including the current study, 16 AAV/IgAN overlap cases were reported. Our five patients with the coexistence of AAV and IgAN were younger than the ten AAV patients with pauci-immune glomerulonephritis (22.6 ± 8.2 years versus 48.9 ± 15.7 years, respectively, P = 0.004). Histologically, they had a significantly lower percentage of glomeruli with fibrous crescents compared with AAV patients (0.0% versus 4.0%, P = 0.038). Compared with ten IgAN patients, our five AAV/IgAN patients had higher levels of ESR (P = 0.032) and CRP (P = 0.031). After accepting treatment with a combination of steroid and immunosuppressants, all patients showed a positive response to therapy, except for one patient in our cohort and another previously reported patient. We described the clinical presentation, pathologic features, treatment response, and outcome data of five patients with overlapping AAV and IgAN. They had mild glomerular pathological lesions and a positive response to aggressive immunosuppressive therapy. They were quite similar to pauci-immune AAV patients in clinical features, except for younger age. They had a lower percentage of glomeruli with fibrous crescents compared with AAV patients. In contrast to IgAN patients, they had higher levels of ESR and CRP. The mechanism of the coexistence of IgAN and AAV needs further study.
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95
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Pyo JY, Ahn SS, Song JJ, Park YB, Lee SW. The Reclassification of Patients With Previously Diagnosed Eosinophilic Granulomatosis With Polyangiitis Based on the 2022 ACR/EULAR Criteria for Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. J Rheumatol 2023; 50:213-218. [PMID: 36109070 DOI: 10.3899/jrheum.220560] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR) have proposed the 2022 classification criteria for eosinophilic granulomatosis with polyangiitis (EGPA). This study applied the 2022 ACR/EULAR criteria to Korean patients with previously diagnosed EGPA to investigate the concordance rate between the 2022 ACR/EULAR criteria and the old criteria for EGPA. METHODS In total, 51 patients with EGPA who met the 1990 ACR criteria, the 2007 European Medicines Agency algorithm, and the 2012 Chapel Hill Consensus Conference definitions were reclassified based on the 2022 ACR/EULAR criteria. RESULTS Of 51 patients, 44 (86.3%) were reclassified as having EGPA according to the 2022 ACR/EULAR criteria. Among the 7 patients who failed to meet the 2022 ACR/EULAR criteria, 3 patients were reclassified as having microscopic polyangiitis (MPA) and 1 was reclassified as having granulomatosis with polyangiitis (GPA) based on the 2022 ACR/EULAR criteria; as well, 3 patients were reclassified as having unclassifiable vasculitis. Moreover, 6 patients who met the 2022 ACR/EULAR criteria for EGPA simultaneously met the criteria for MPA based on the 2022 ACR/EULAR criteria for MPA, and 1 who met the criteria for EGPA simultaneously met the criteria for GPA based on the 2022 ACR/EULAR criteria for GPA. CONCLUSION The concordance rate between the 2022 ACR/EULAR criteria for EGPA and the old criteria was 86.3%. The most important factor in the failure to reclassify patients as having EGPA was the exclusion of nonfixed pulmonary infiltrates in the 1990 ACR criteria for EGPA. We cautiously suggest reconsidering nonfixed pulmonary infiltrates in cases reclassified as unclassifiable vasculitis. Further, additional classification strategies are needed for patients who simultaneously satisfy both antineutrophil cytoplasmic antibody-associated vasculitis subtypes.
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Affiliation(s)
- Jung Y Pyo
- J.Y. Pyo, MD, S.S. Ahn, MD, PhD, Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine
| | - Sung S Ahn
- J.Y. Pyo, MD, S.S. Ahn, MD, PhD, Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine
| | - Jason J Song
- J.J. Song, MD, PhD, Y.B. Park, MD, PhD, S.W. Lee, MD, PhD, Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, and Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Beom Park
- J.J. Song, MD, PhD, Y.B. Park, MD, PhD, S.W. Lee, MD, PhD, Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, and Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang-Won Lee
- J.J. Song, MD, PhD, Y.B. Park, MD, PhD, S.W. Lee, MD, PhD, Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, and Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea.
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96
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Dammacco R, Biswas J, Mohanan-Earatt A, Lisch W, Zito FA, Rubini G, Manno C, Cicco S, Alessio G, Dammacco F. The eye is a common site of granulomatosis with polyangiitis. A collaborative study. BMC Ophthalmol 2023; 23:26. [PMID: 36653761 PMCID: PMC9850589 DOI: 10.1186/s12886-022-02743-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 12/16/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Ocular manifestations of granulomatosis with polyangiitis (GPA) have been reported in a limited number of studies and with largely variable frequency. Here we report on the clinical, diagnostic, and therapeutic features of a cohort of 63 GPA patients, with particular regard to 22 of them with ophthalmic involvement (35%). METHODS Clinical manifestations, results of immunological findings, histopathological pictures, imaging data, Birmingham Vasculitis Activity Score, therapeutic regimens, and outcomes were retrospectively analyzed. At diagnosis, in addition to a structured clinical assessment, all patients underwent a comprehensive ophthalmologic examination. RESULTS The most frequently involved organs were kidneys, lungs, ear/nose/throat, and eyes. Ocular manifestations were bilateral in 32%. The three most commonly diagnosed ophthalmologic manifestations were scleritis (36%), retro-orbital pseudotumor or orbital mass (23%), and episcleritis (13%). Ocular and systemic involvement were simultaneously present at onset in 41% of the patients; systemic involvement was followed by ocular lesions in 36%; ocular inflammation was followed by systemic manifestations in 18%; and an orbital mass in the absence of systemic disease characterized 5%. Glucocorticoids plus cyclophosphamide and glucocorticoids plus rituximab were the combined therapies most frequently employed during remission induction and remission maintenance, respectively. Persistent ophthalmologic and extra-ocular remissions were achieved in 77 and 64% of the patients, respectively. One to three systemic relapses were diagnosed in 7 patients (31.8%). At the last follow-up, a visual outcome 20/40 or better in 31 (70%) of 44 eyes was determined. CONCLUSIONS The eye was involved in over one third of our patients with GPA. Increased awareness, early diagnosis, and multi-specialty collaboration are critical in achieving a favorable outcome of GPA.
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Affiliation(s)
- Rosanna Dammacco
- grid.7644.10000 0001 0120 3326Department of Ophthalmology and Neuroscience, University of Bari “Aldo Moro”, Medical School, Bari, Italy
| | - Jyotirmay Biswas
- grid.414795.a0000 0004 1767 4984Department of Uveitis and Ocular Pathology, Sankara Nethralaya, Chennai, India
| | - Amanda Mohanan-Earatt
- grid.414795.a0000 0004 1767 4984Department of Uveitis and Ocular Pathology, Sankara Nethralaya, Chennai, India
| | - Walter Lisch
- grid.5802.f0000 0001 1941 7111Department of Ophthalmology, Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Giuseppe Rubini
- grid.7644.10000 0001 0120 3326Nuclear Medicine Unit, University of Bari Medical School, Bari, Italy
| | - Carlo Manno
- grid.7644.10000 0001 0120 3326Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplant Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Sebastiano Cicco
- grid.7644.10000 0001 0120 3326Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Medical School, Bari, Italy
| | - Giovanni Alessio
- grid.7644.10000 0001 0120 3326Department of Ophthalmology and Neuroscience, University of Bari “Aldo Moro”, Medical School, Bari, Italy
| | - Franco Dammacco
- grid.7644.10000 0001 0120 3326Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Medical School, Bari, Italy
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Santos-Moreno P, Arias-Aponte J, Rodríguez-Vargas GS, Nieto-Zambrano PD, Villarreal L, Ibatá L, Martinez S, Rubio-Rubio JA, Rodríguez P, Rojas-Villarraga A. Polyautoimmunity in systemic lupus erythematosus patients: New insights from a cross-sectional study. J Transl Autoimmun 2023; 6:100187. [PMID: 36654852 PMCID: PMC9841268 DOI: 10.1016/j.jtauto.2022.100187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023] Open
Abstract
Objective To assess the frequency of polyautoimmunity (PolyA) in a cohort of Colombian patients with systemic lupus erythematosus (SLE) and to identify associated factors. Methods This is an analytical cross-sectional study in a specialized center., a comprehensive review of the medical records of SLE patients was performed from 2015 to 2020 in order to obtain demographic, clinical data, laboratory, and treatment information. Associations between PolyA, demographic, and characteristics of the disease were explored. Results A total of 463 patients were included in the analysis. The average age was 47.3 ± 15 years. Most of this population were female (87.4%), whom were diagnosed with SLE in a long-term SLE (10.6 ± 10.1 years). Out of the total patients, 34.7% were diagnosed with PolyA. Among the most frequent clinical criteria for SLICC, arthritis (65%), kidney impairment (39.5%), and alopecia (34.8%) were found. The most frequent SLE-associated PolyA were antiphospholipid syndrome (APS) and Sjögren's syndrome (SS) (16.63% and 10.58%, respectively). PolyA-associated factors were age, xerophthalmia, central nervous system occlusion, and deep vein thrombosis (DVT). In contrast, renal impairment was significantly less frequent in PolyA patients after multivariate analysis. Conclusion The results have showed associated factors with PolyA like age, xerophthalmia, central nervous system occlusion, and deep vein thrombosis in this cohort. On the other hand, lupus nephritis was less frequent in patients with PolyA. This study provides a spotlight of a specific SLE population as real-life evidence for a better characterization of PolyA in the future.
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Affiliation(s)
- Pedro Santos-Moreno
- Scientific Direction, Biomab Center for Rheumatoid Arthritis, Bogotá, D.C., 110221, Colombia,Corresponding author.
| | - Julián Arias-Aponte
- Research Vice-rectory, Fundación Universitaria de Ciencias de La Salud-FUCS, Bogotá D.C, 111411, Colombia
| | | | | | - Laura Villarreal
- Medical Direction, Biomab Center for Rheumatoid Arthritis, Bogotá, D.C., 110221, Colombia
| | - Linda Ibatá
- Epidemiology, Biomab IPS, Bogotá, D.C, 110221, Colombia
| | | | - Jaime-Andrés Rubio-Rubio
- Research Institute, Fundación Universitaria de Ciencias de La Salud FUCS, Bogotá, D.C, 111411, Colombia
| | - Pedro Rodríguez
- Scientific Direction, Biomab Center for Rheumatoid Arthritis, Bogotá, D.C., 110221, Colombia
| | - Adriana Rojas-Villarraga
- Research Institute, Fundación Universitaria de Ciencias de La Salud FUCS, Bogotá, D.C, 111411, Colombia
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Sinonasal Amoebiasis: An Unexpected Cause of Sinonasal Necroinflammatory Disease. Am J Surg Pathol 2023; 47:102-110. [PMID: 35968953 DOI: 10.1097/pas.0000000000001951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
While amoebic infection is widely known as a cause of gastroenteritis, keratitis, and meningoencephalitis, amoebae are challenging to recognize at unexpected sites. Despite multiple case reports of sinonasal amoebiasis, amoebic infection is not regularly considered in the differential diagnosis of sinonasal necroinflammatory disease. Here, we aim to characterize the pathologic features of sinonasal amoebiasis to facilitate better recognition. We identified sinonasal amoebiasis in 4 men, median age of 67 years (range: 37 to 71 y). All were immunocompromised, including 2 with chronic lymphocytic leukemia, 1 with human immunodeficiency virus, and 1 with human immunodeficiency virus and kidney transplant. Patients presented with nasal mucosal necrosis or polypoid masses, with facial ulceration in 1 patient and distant dermal nodules in another. Biopsies displayed extensive necrotic debris and inflammation. Although amoebic cysts were abundant in 3 cases, they were mistaken for yeast at frozen section in 1 case; 1 case showed only rare trophozoites that were not recognized on initial biopsy. Periodic acid Schiff and Grocott Methenamine Silver stains highlighted the organisms, and polymerase chain reaction confirmed Acanthamoeba species in 3 cases tested. 2 patients responded well to antiprotozoal medications, but 2 died of disease. Overall, sinonasal amoebiasis presents as a necroinflammatory process in patients immunocompromised for various reasons. Amoebae can mimic other organisms or be incredibly scarce, requiring active consideration to recognize amoebiasis and differentiate it from overlapping conditions like invasive fungal sinusitis, granulomatosis with polyangiitis, and natural killer/T-cell lymphoma. Because sinonasal amoebiasis is highly treatable when diagnosed promptly, pathologists play a critical role in the recognition of this rare necroinflammatory disease.
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99
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Pan M, Zhao H, Jin R, Leung PSC, Shuai Z. Targeting immune checkpoints in anti-neutrophil cytoplasmic antibodies associated vasculitis: the potential therapeutic targets in the future. Front Immunol 2023; 14:1156212. [PMID: 37090741 PMCID: PMC10115969 DOI: 10.3389/fimmu.2023.1156212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/27/2023] [Indexed: 04/25/2023] Open
Abstract
Anti-neutrophil cytoplasmic autoantibodies (ANCA) associated vasculitis (AAV) is a necrotizing vasculitis mainly involving small blood vessels. It is demonstrated that T cells are important in the pathogenesis of AAV, including regulatory T cells (Treg) and helper T cells (Th), especially Th2, Th17, and follicular Th cells (Tfh). In addition, the exhaustion of T cells predicted the favorable prognosis of AAV. The immune checkpoints (ICs) consist of a group of co-stimulatory and co-inhibitory molecules expressed on the surface of T cells, which maintains a balance between the activation and exhaustion of T cells. CD28, inducible T-cell co-stimulator (ICOS), OX40, CD40L, glucocorticoid induced tumor necrosis factor receptor (GITR), and CD137 are the common co-stimulatory molecules, while the programmed cell death 1 (PD-1), cytotoxic T lymphocyte-associated molecule 4 (CTLA-4), T cell immunoglobulin (Ig) and mucin domain-containing protein 3 (TIM-3), B and T lymphocyte attenuator (BTLA), V-domain Ig suppressor of T cell activation (VISTA), T-cell Ig and ITIM domain (TIGIT), CD200, and lymphocyte activation gene 3 (LAG-3) belong to co-inhibitory molecules. If this balance was disrupted and the activation of T cells was increased, autoimmune diseases (AIDs) might be induced. Even in the treatment of malignant tumors, activation of T cells by immune checkpoint inhibitors (ICIs) may result in AIDs known as rheumatic immune-related adverse events (Rh-irAEs), suggesting the importance of ICs in AIDs. In this review, we summarized the features of AAV induced by immunotherapy using ICIs in patients with malignant tumors, and then reviewed the biological characteristics of different ICs. Our aim was to explore potential targets in ICs for future treatment of AAV.
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Affiliation(s)
- Menglu Pan
- Department of Rheumatology and Immunology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Huanhuan Zhao
- Department of Rheumatology and Immunology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ruimin Jin
- Department of Rheumatology and Immunology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Patrick S. C. Leung
- Division of Rheumatology/Allergy and Clinical Immunology, University of California, Davis, Davis, CA, United States
- *Correspondence: Zongwen Shuai, ; Patrick S. C. Leung,
| | - Zongwen Shuai
- Department of Rheumatology and Immunology, First Affiliated Hospital of Anhui Medical University, Hefei, China
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China
- *Correspondence: Zongwen Shuai, ; Patrick S. C. Leung,
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100
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Gesierich W, Popp F, Welcker M. Lungenfibrose als Spätmanifestation einer ANCA-assoziierten Vaskulitis? PNEUMO NEWS 2023; 15:6-9. [PMID: 37128241 PMCID: PMC10132916 DOI: 10.1007/s15033-023-3484-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Affiliation(s)
- Wolfgang Gesierich
- Zentrum für Pneumologie und Thoraxchirurgie, Asklepios Fachklinik München-Gauting, Robert-Koch-Allee 2, 82131 Gauting, Deutschland
| | - Florian Popp
- MVZ für Rheumatologi, Bahnhofstraße 32, 82152 Planegg, Deutschland
| | - Martin Welcker
- Rheumapraxis Dr. Welcker und Kollegen, Bahnhofstr. 32, 82152 Planegg (bei München), Deutschland
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