The American College of Rheumatology 1990 criteria for the classification of Churg-Strauss syndrome (allergic granulomatosis and angiitis)

Churg-Strauss syndrome presenting as myositis following unaccustomed exercise

A 68-year-old woman with a 4 year history of bronchial asthma developed marked myalgia in the extremities following exercise to which she was unaccustomed. Examination on admission, 11 days after onset, revealed myalgia, muscular weakness and cutaneous hemorrhagic bullae. Blood tests revealed eosinophilia (9160/mm(3)) and elevation of creatinine kinase and C-reactive protein. Muscle biopsy in the quadriceps femoris showed small vessel vasculitis and eosinophilic infiltration. Skin biopsy revealed leukocytoclastic vasculitis with neutrophilic and eosinophilic infiltration and fibrinoid necrosis. We diagnosed her as having Churg-Strauss syndrome (CSS). Corticosteroid treatment relieved her symptoms and resulted in normalization of the laboratory test results. Myositis is rare as an initial manifestation of CSS. The previous studies on immunological changes after eccentric exercise suggest that unaccustomed exercise could induce an increase in the serum level of interleukin-6 and trigger the onset of CSS.

A case of churg-strauss syndrome

Churg-Strauss syndrome (CSS) or allergic granulomatosis angiitis is a rare primary vasculitic disease. CSS can be diagnosed by the presence of any four or more of the six criteria, which include asthma, eosinophilia greater than 10%, paranasal sinusitis, pulmonary infiltration, histological proof of vasculitis and mono- or poly-neuropathy. We report here on a 45-year-old male who developed erythematous macules, papules and hemorrhagic vesicles on both right extremities along with a tingling sensation and sacral pain. He has been suffering from recurrent allergic rhinitis and bronchial asthma for 6 months. The laboratory findings showed severe eosinophilia (22.3%), hyper-IgE and positivity for p-ANCA. On the histological examination of the hemorrhagic vesicle on the right lower leg, leukocytoclsatic vasulitis and many neutrophils and eosinophils around the cutaneous vessels were observed in the dermis.

Churg-strauss syndrome in patients treated with omalizumab

BACKGROUND

Churg-Strauss syndrome (CSS) is a rare systemic vasculitis associated with asthma, eosinophilia, sinusitis, and pulmonary infiltrates. CSS has been reported in association with asthma therapies.

MATERIALS AND METHODS

The objective is to describe the characteristics of CSS in patients treated with the anti-IgE antibody omalizumab (Xolair; Genentech Inc; South San Francisco, CA). A retrospective review of available data to identify cases of CSS was performed using the Novartis Argus global drug safety database for omalizumab in asthma patients.

RESULTS

We identified 34 potential cases of CSS. Of these, 13 cases fulfilled at least four of the six criteria identified in the American College of Rheumatology classification criteria. Eight of the patients in these 13 definite or probable cases (62%) had CSS symptoms prior to receiving omalizumab or described symptom onset just after corticosteroid weaning. Six of the 13 patients (46%) were confirmed as having been treated with corticosteroids for what was perceived to be severe asthma; when corticosteroids were tapered in conjunction with omalizumab treatment, CSS symptoms appeared just after the tapering. There were 4 other cases of possible CSS, and the remaining 17 patients were judged to not have CSS.

CONCLUSIONS

CSS may develop in patients receiving asthma medications who have an underlying eosinophilic disorder that is unmasked by the withdrawal of therapy with corticosteroids, or in patients who delay therapy in favor of other medications. Omalizumab treatment may unmask CSS due to the weaning of corticosteroids in some asthma patients or may delay corticosteroid treatment allowing for CSS to manifest.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00252135.

Branch retinal vein occlusion followed by central retinal artery occlusion in Churg-Strauss syndrome: unusual ocular manifestations in allergic granulomatous angiitis

PURPOSE

To describe a rare branch retinal vein occlusion (BRVO) followed by central retinal artery occlusion (CRAO) in a patient with Churg-Strauss syndrome (CSS).

METHODS

A 55-year-old man with a not yet diagnosed CSS developed a BRVO in the left eye and 1 year later a CRAO with painless and acute vision loss in the same eye. Medical history included bronchial asthma, history of allergy, eosinophilic pneumonia, bilateral pleuric and pericardial effusion, hypereosinophilia, and purpuric vasculitis.

RESULTS

CRAO in the left eye was diagnosed by retinal whitening and a cherry red spot with coexisting old BRVO evidenced by previous laser photocoagulation. Corticosteroids and cyclophosphamide therapy improved his general condition but no visual recovery occurred.

CONCLUSIONS

BRVO and CRAO can occur in the same eye in CSS. In the presence of systemic signs or symptoms, it is important to rule out systemic vasculitis in order to start appropriate immune-modulatory treatment thereby avoiding unnecessary mortality.

High frequency of venous thromboembolic events in Churg-Strauss syndrome, Wegener's granulomatosis and microscopic polyangiitis but not polyarteritis nodosa: a systematic retrospective study on 1130 patients

OBJECTIVE

To determine the frequency and risk factors of venous thromboembolic events (VTE) in Wegener's granulomatosis (WG), microscopic polyangiitis (MPA) and, the so far unstudied, Churg-Strauss syndrome (CSS) and polyarteritis nodosa (PAN).

METHODS

Retrospective, systematic analysis and comparisons were made between the characteristics of patients in the VTE group and non-VTE group. 1130 patients with WG, MPA, CSS or PAN were identified from the French Vasculitis Study Group cohort.

RESULTS

During a mean follow-up of 58.4 (45.8) months, 83 VTE occurred in 74 (6.5%) patients, with a median vasculitis-VTE diagnosis interval of 5.8 months (-3 to +156). VTE occurred in seven of 285 (2.5%) patients with PAN, 19 of 232 (8.2%) with CSS, 30 of 377 (8%) with WG and 18 of 236 (7.6%) with MPA. Multivariate analysis retained age, male sex or previous VTE or stroke with motor deficit as being associated with a higher VTE risk. The adjusted odds ratio (95% confidence interval) for VTE was 2.88 (1.27 to 6.50) for patients with WG, MPA or CSS compared with PAN (p = 0.01).

CONCLUSIONS

Our results suggest that, like WG and MPA, patients with CSS are at a greater risk of VTE, than those with PAN. The reasons for this difference remain to be elucidated.

Persistent airflow obstruction in asthma of patients with Churg-Strauss syndrome and long-term follow-up

BACKGROUND

Little is known about the long-term outcome of airflow obstruction in asthma of patients with Churg-Strauss syndrome (CSS).

METHODS

We conducted a retrospective study of 24 consecutive patients (aged 41.1 +/- 13.5 years) with CSS in a single center. All had asthma (starting 8.1 +/- 9.5 years prior to the diagnosis of CSS), blood eosinophilia (6.1 +/- 4.4 x 10(9)/l) and systemic manifestations of CSS. Antineutrophil cytoplasmic antibodies were found in 7 of 22 tested patients. Seven patients had smoked (a mean of 10 pack-years). All patients received oral corticosteroids, 11 cyclophosphamide and 23 inhaled corticosteroids.

RESULTS

Airflow obstruction was found in 14 patients (70%) at diagnosis, and in 11 of 22 patients (50%) at the time of the clinical remission of CSS. The mean postbronchodilator FEV1/FVC and FEV1 were 69 +/- 12% and 74 +/- 21% of predicted at diagnosis (n = 20); 71 +/- 10% and 92 +/- 19% of predicted at the clinical remission (n = 22); and 64 +/- 13% and 80 +/- 21% at last visit (n = 13), respectively. During follow-up, postbronchodilator FEV1 increased by 30 +/- 28% in six patients with FEV1/FVC < 70% despite inhaled therapy who received higher dose of oral corticosteroids. At last visit, 5 of 13 patients (38%) with more than 3 years of follow-up had persistent airflow obstruction as defined by postbronchodilator FEV1/FVC < 70% and FEV1 < 80% of predicted.

CONCLUSION

Airflow obstruction due to uncontrolled asthma is present despite corticosteroids in many patients at diagnosis and at clinical remission of CSS, and during follow-up. It may be still partly reversible with increased oral corticosteroid treatment.

Fluticasone-associated cutaneous allergic granulomatous vasculitis: an underrecognized but important cause of drug-induced cutaneous Churg-Strauss syndrome

Allergic granulomatous vasculitis, or Churg-Strauss syndrome, is a small vessel, multisystem vasculitis that can affect multiple organs. It is usually idiopathic, but recent case reports have implicated leukotriene receptor antagonists (LTRA) and inhaled corticosteroids in the development of this rare syndrome. We report a case that acutely developed skin-limited Churg Strauss-like cutaneous allergic granulomatous vasculitis after initiating therapy with inhaled fluticasone and salmeterol for poorly controlled asthma symptoms. Our result thus highlights the importance of keeping the differential diagnosis of drug-induced Churg-Strauss syndrome in patients who have recently been prescribed inhaled steroids like fluticasone when they present with rashes of varying severity.

A laryngeal presentation of Churg-Strauss syndrome in childhood

A 10- year-old female, known to have bronchial asthma, presented with an unusual laryngeal lesion, eventually diagnosed as Churg-Strauss syndrome (CSS). She was referred to our hospital with history of recurrent stridor. On endoscopyhe, the larynx showed signs similar to recurrent respiratory papillomatosis (RRP). CSS is a systemic disorder and is now defined as one of the ANCA ( antineutrophil cytoplasmic antibodies)-associated vasculitides. CSS is a systemic disease that may involve unusual sites like the larynx. Such an unusual presentation of CSS should be kept in mind, especially in patients with history of asthma.

Are classification criteria for vasculitis useful in clinical practice? Observations and lessons from Colombia

INTRODUCTION

Idiopathic systemic vasculitis represents a group of clinical entities having non-specific etiology with the common characteristic of acute or chronic inflammatory compromise of the small and large vessels walls, associated with fibrinoid necrosis.

OBJECTIVES

To describe the most common inflammatory vascular diseases in a long historical cohort of patients from San Juan de Dios Hospital located in Bogota, Colombia using two different systems and a clinical histopathological correlation format, and to make a comparison between them.

METHODS

We reviewed all previously ascertained cases of vasculitis confirmed by biopsy processed between 1953 and 1990, and systematically collected data on all new cases of vasculitis from 1991 to 1997 at the Hospital San Juan de Dios (Bogota-Colombia). The cases were classified in accordance with the Chapel Hill Consensus criteria, and the system proposed by J.T. Lie.

RESULTS

Of 165,556 biopsy tissue specimens obtained during this period from our hospital, 0.18% had vasculitis, perivasculitis or vasculopathy. These included 304 histopathological biopsies from 292 patients. Cutaneous leukocytoclastic vasculitis (64 histological specimens) was the most frequently encountered type of "primary" vasculitis followed by thromboangiitis obliterans (38 specimens), and polyarteritis nodosa (24 specimens). Vasculitis associated with connective tissue diseases (33 specimens) and infection (20 specimens) were the main forms of secondary vasculitis, a category that was omitted from the Chapel Hill consensus report. We found that 65.8% of our histopathological diagnoses could not be classified according to the Chapel Hill classification, and 35.2% could not be classified according to the classification of Lie. Only 8.9% of cases remained unclassified by our system after clinical and histological correlation.

CONCLUSION

Current vasculitis classification schemes are designed for classification, rather that diagnosis of disease and do not adequately address some common forms of inflammatory vascular diseases, including those of infectious etiology and unusual etiology seen in clinical practice. Based on our clinical experience, we suggest a classification outline which practitioners can use which emphasizes correlation of the clinical picture to the histopathology findings for diagnosis and therapy, which may promote better clinical practice and standardization for clinical trials.

Postpartum Churg-Strauss syndrome with severe cardiac involvement: description of a case and review of the literature

Churg-Strauss syndrome (CSS) is a rare small- or intermediate-vessel necrotizing vasculitis typically characterized by asthma, lung infiltrates, necrotizing granulomas, and hypereosinophilia. In this report, we describe the case of a 35-year-old woman who, during her third trimester of pregnancy, developed dyspnea and, after delivery, severe cardiac failure which required heart transplantation. Diagnosis of CSS was made after performing a myocardial biopsy. We have also undertaken a review of the English-language literature regarding previously reported cases of pregnancies in women suffering from Churg-Strauss syndrome with particular attention to those patients with cardiovascular involvement.

Churg-Strauss syndrome: a rare presentation with otological and pericardial manifestations: case report and review of the literature

Churg-Strauss syndrome (CSS) is a rare multisystem autoimmune disease characterized by diffuse eosinophilic infiltration and necrotizing vasculitis. There are typical manifestations of longstanding rhinosinusitis and polyposis but otological manifestations are rare and characterized by dense aural discharge, granulomatous eosinophilic infiltrate in the mastoid and middle ear with conductive hearing loss, and progressive sensory neural hearing loss--all of which are not responsive to conventional treatment. We describe the case of a 59-year-old man with a rare presentation of CSS that included chronic bilateral otitis media with hearing loss and life-threatening pericardial tamponade. Treatment with pericardiocentesis, prednisone and cyclophosphamide was beneficial and resulted in an improvement of the pericardial and otological manifestations. Early recognition and treatment of otological involvement in CSS is extremely important because of the dramatic response to corticosteroids which may prevent progression of hearing loss.

Outcome of thirty patients with ANCA-associated renal vasculitis admitted to the intensive care unit

The natural course of as-yet-untreated ANCA-associated vasculitis (AAV) or complications of immunosuppressive treatment may result in rapid clinical deterioration with the need of admission to an intensive care unit (ICU). The aim of this retrospective study was to assess the outcome of patients with renal AAV admitted to the ICU in a single center. We reviewed the medical records of all 218 patients with AAV followed in our department between January 2001 and December 2006 and selected those admitted to the ICU. To assess the severity of critical illness, the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) score on the first ICU day were calculated. Birmingham Vasculitis Activity Score (BVAS) was calculated to represent the total disease activity. Thirty patients with AAV (11 women, 19 men; mean age 61.5 +/- 13.2 years; 20 x cANCA, 10 x pANCA positive) were included. The most common reasons for ICU admission were as follows: active vasculitis (13 patients, 43.3 %), infections (7 patients, 23.3%), and other causes (10 patients, 33.3%). The in-ICU mortality was 33.3% (10 patients). The most common cause of death was septic shock (in 5 patients). The APACHE II (33.5 vs. 23.8) and SOFA scores (11.9 vs. 6.6), but not BVAS (11.5 vs. 16.1), were statistically significantly higher in non-survivors than in survivors (p < 0.01). In conclusion, the in-ICU mortality in AAV patients may be predicted by APACHE II and SOFA scores. While active vasculitis is the most frequent reason for ICU admission, the mortality rate is highest in patients with infectious complications.

Magnetic resonance imaging of a hypereosinophilic endocarditis with apical thrombotic obliteration in Churg-Strauss syndrome complicated with acute abdominal aortic embolic occlusion

Churg-Strauss syndrome can be associated with Loeffler-like eosinophilic endocarditis. We report a case of a young woman in which the diagnosis of Churg-Strauss syndrome was made subsequently to the magnetic resonance demonstration of eosinophilic endocarditis associated to left ventricle apical thrombosis. In our report, this rare condition evolved in an unusual complication: the embolic migration of the left ventricle apical thrombus in the abdominal aorta as showed by multi-detector-computed-tomography angiography.

Churg-Strauss syndrome: 2005-2008 update

Churg-Strauss syndrome (CSS) is a rare necrotizing small-vessel vasculitis associated with eosinophil-rich granulomatous inflammation of tissues and vessels and is also associated with asthma and eosinophilia. Epidemiologic studies continue to show that CSS is the rarest of the necrotizing small-vessel vasculitides. However, it is not possible to know with any certainty if there has been an increase in incidence. There has been an attempt to divide the patients with CSS into an antineutrophil cytoplasmic antibody-positive and cytoplasmic antibody-negative group. The former group has an increased frequency of renal involvement, parenchymal pulmonary disease, constitutional symptoms, and peripheral and central nervous system involvement, whereas the latter group has more frequent cardiac disease. The role of eosinophils and antineutrophil cytoplasmic antibodies remains poorly defined but provocative. Leukotriene receptor antagonists do not appear to induce CSS but facilitate the tapering of glucocorticoids, which unmasks the condition. Glucocorticoids and cyclophosphamide remain the foundation of treatment for vasculitis, but there are other promising and less toxic alternatives on the horizon.

Surgically induced necrotizing scleritis and optic neuropathy after pars plana vitrectomy as presenting signs of churg-strauss syndrome

PURPOSE

To report a case of surgically induced necrotizing scleritis and optic neuropathy after pars plana vitrectomy as presenting signs of Churg-Strauss syndrome.

METHOD

Case report.

RESULTS

A 59-year-old Asian man underwent a 20-gauge pars plana vitrectomy to remove a posteriorly dislocated intraocular lens. During follow-up, he developed unilateral necrotizing scleritis and optic neuropathy. Systemic evaluation and laboratory investigations revealed findings consistent with Churg-Strauss syndrome. Systemic corticosteroids therapy produced dramatic improvement in visual symptoms.

CONCLUSION

Churg-Strauss syndrome should be considered in any patient who develops surgically induced necrotizing scleritis and/or optic neuropathy after pars plana vitrectomy. Prompt and aggressive treatment with systemic corticosteroids can result in marked improvement.

Rare manifestations of Churg-Strauss syndrome: coronary artery vasospasm, temporal artery vasculitis, and reversible monocular blindness-a case report

Churg-Strauss syndrome (CSS) is a rare illness with clinical findings characterized by asthma, eosinophilia, and vasculitis affecting medium and small-sized arteries and veins in a variety of organs. Involvement of the temporal arteries by non-giant cell eosinophilic vasculitis in CSS is quite rare and has only been published as isolated case reports or small patient series. Myocardial infarction due to coronary artery vasospasm is an unusual manifestation of CSS. We describe a case of a 39-year-old woman who had two myocardial infarctions due to severe coronary artery vasospasm and was diagnosed with CSS based on a temporal artery biopsy. During the course of her treatment, she also had another rare manifestation of CSS, monocular blindness reversible with immunosuppressive therapy.

Rhinologic symptoms and quality-of-life in patients with Churg-Strauss syndrome vasculitis

BACKGROUND

The purpose of this study was to investigate the presentation pattern, sinonasal symptoms, and quality of life (QOL) in patients with Churg-Strauss syndrome (CSS) vasculitis.

METHODS

A cross-sectional study was performed. Twenty-five patients with CSS belonging to a patient self-help group participated. Main outcome measures included mode of initial presentation, treatment, rhinologic symptoms, and disease-specific QOL (Sinonasal Outcome Test [SNOT-22] scores) and comparisons were made with general rhinosinusitis and other nasally affected vasculitis patients (Wegener's granulomatosis [WG]).

RESULTS

Overall, 80% of CSS patients had active sinonasal symptoms at the time of the study. Twenty-eight percent of CSS patients reported worsening of their nasal symptoms as the main event leading to their diagnosis. Forty-eight percent of CSS patients had undergone nasal surgery. Nasal symptoms that are of particular relevance to this patient group are nasal obstruction (95%), rhinorrhea (95%), anosmia (90%), and excessive sneezing (80%). Other symptoms included nasal crusting (75%), purulent nasal discharge (65%), and epistaxis (60%). SNOT-22 scores were significantly higher than normal, reaching average values similar to those of patients from the general rhinosinusitis population.

CONCLUSION

Sinonasal symptoms are common at initial presentation of CSS, emphasizing the role of otolaryngologists in its diagnosis. Overall, CSS-related sinonasal morbidity is significant and comparable with that of the general rhinosinusitis population. It predominantly results from symptoms of allergic rhinitis, but a significant proportion of CSS patients also report milder forms of crusting, epistaxis, and of purulent sinusitis, symptoms which are more commonly attributed to patients with WG.

Epidemiology of primary systemic vasculitis in the Australian Capital Territory and south-eastern New South Wales

BACKGROUND

The aim of the study was to determine the epidemiology of primary systemic vasculitis in the Australian Capital Territory and the surrounding rural region between 1995 and 2005.

METHODS

Cases were ascertained by a medical record search according to international consensus classification criteria. For antineutrophil cytoplasmic antibody-associated vasculitides, ascertainment was corroborated by a search of all positive antineutrophil cytoplasmic antibody serology during the study period. Denominators were obtained from region-specific census data collected during the study period. Prevalence, incidence and patient characteristics for primary systemic vasculitides were determined for two 5-year periods, 1995-1999 and 2000-2004.

RESULTS

We identified 41 cases of primary systemic vasculitides (Wegener's granulomatosis (WG), microscopic polyangiitis (MPA), Churg-Strauss syndrome or polyarteritis nodosa) between 1995 and 1999 and 67 between 2000 and 2004, giving prevalences of 95/million (95% confidence interval (CI) 76.9-116.1) and 148/million (95%CI 125.1-173.9), respectively. Annual incidence was similar in both periods (approximately 17/year per million adult population). Disease-specific incidences (per million per year) for each of the two periods were 8.8 and 8.4 for WG, 2.3 and 5.0 for MPA, 2.3 and 2.2 for Churg-Strauss syndrome and 2.3 and 1.1 for polyarteritis nodosa. The rural incidence of MPA was 13.9 (95%CI 7.7-23.5) compared with 1.6 (95%CI 0.2-7.2) in the city and there was a trend towards a higher incidence of WG in rural than urban areas.

CONCLUSION

The overall incidence of primary systemic vasculitides is similar to that reported from other developed countries. WG is more common in south-eastern Australia than in southern Europe, whereas MPA is less common. There was a trend towards higher incidence of antineutrophil cytoplasmic antibody-associated vasculitides in rural than urban areas.

Cardiovascular magnetic resonance imaging detects cardiac involvement in Churg-Strauss syndrome

BACKGROUND

Cardiac involvement in Churg-Strauss vasculitis worsens the prognosis. Early detection is, therefore, warranted. Cardiac magnetic resonance (CMR) can visualize various forms of inflammatory changes in the myocardium. We tested whether CMR could elucidate cardiac damage in patients with biopsy-proven Churg-Strauss syndrome and clinical evidence of cardiac involvement.

METHODS AND RESULTS

Eleven patients underwent a CMR protocol including cine imaging for left ventricular function in long axes, T2-weighted imaging for edema detection, and contrast-enhanced T1-weighting for early and late gadolinium enhancement. CMR detected various form of myocardial injury in all patients. Systolic left ventricular function was impaired in 6 patients. Mean left ventricular ejection fraction was 45 +/- 15%. Left ventricular size was mildly enlarged (left ventricular end-diastolic volume index 94 +/- 23 mL/m(2)). Edema was present in 4 cases; 7 patients had pericardial effusion. Six patients had increased early contrast uptake. CMR detected late enhancement lesions in 9 of 11 patients, even in those with normal left ventricular size and function.

CONCLUSIONS

CMR has the potential to detect myocardial injury in Churg-Strauss syndrome even when left ventricular function appears normal.

ANCA-negative glomerulonephritis associated with nonasthmatic Churg-Strauss syndrome

BACKGROUND

A 36-year-old white male with a history of allergic rhinitis and sinusitis presented to the emergency room with abdominal pain and diarrhea. Physical examination revealed fever, hypoxemia and a maculopapular rash. Laboratory tests showed proteinuria, hematuria, leukocytosis, eosinophilia and an elevated erythrocyte sedimentation rate.

INVESTIGATIONS

Physical examination, urine and blood analysis and culture, chest radiography, chest and abdominal CT, esophagogastroduodenoscopy, skin and kidney biopsy, serology and renal ultrasound.

DIAGNOSIS

Pauci-immune focal necrotizing glomerulonephritis with crescents and interstitial eosinophilia, consistent with Churg-Strauss syndrome.

MANAGEMENT

The patient was treated with methylprednisolone 1 g/day intravenously for 3 days. He also received oral clotrimazole and combined oral sulfamethoxazole and trimethoprim for prophylaxis against candidiasis and pneumonia, respectively. He left the hospital against medical advice and was lost to follow-up.

Repressed ileal artery aneurysms in Churg-Strauss syndrome following combination treatment with glucocorticoid and cyclophosphamide

Churg-Strauss syndrome (CSS) is a systemic small-vessel vasculitis characterized by asthma and eosinophilia. We report a case of CSS complicated by multiple aneurysms in the small intestine. A 57-year-old man was admitted to our hospital with fever and blood eosinophilila. During admission, aneurysms in his small intestine ruptured and partial resection of the small intestine was required. After combination therapy of glucocorticoid (GC) and cyclophosphamide (CYC) for 6 months, aneurysms in the small intestine disappeared. The gastrointestinal involvements usually result in poor prognosis in CSS. However, combination therapy of GC and CYC might be effective for remission of aneurysms caused by small vessel vasculitis.

Churg-Strauss syndrome in childhood: a systematic literature review and clinical comparison with adult patients

OBJECTIVE

To describe the clinical characteristics of children with Churg-Strauss syndrome (CSS) in comparison with adult patients.

MATERIALS AND METHODS

A systematic literature analysis was performed in the Medline database up to November 2007 and in rheumatology and pulmonology meeting scientific abstracts 2003-2007. Articles with reported childhood CSS cases were retrieved; clinical data were recorded. Descriptive statistical analyses and a comparison with 2 published adult CSS cohorts were performed.

RESULTS

Thirty-three cases of childhood CSS were identified. The mean age was 12 years and the male-to-female ratio was 0.74. All patients had significant eosinophilia and asthma. Histological evidence of eosinophilia and/or vasculitis was present in virtually all patients. Antineutrophil cytoplasmic antibodies were found in 25% of children with CSS. Initial treatment was corticosteroid monotherapy in 76% of childhood CSS patients, while 24% received additional immunosuppressive therapy. Another 18% required further immunosuppression at follow-up due to frequent relapses. Six deaths (18%), all related to the underlying disease, occurred after a mean disease duration of 14 months. As compared with adult CSS patients, children had a predominance of cardiopulmonary disease manifestations, a lower rate of peripheral nerve involvement, and higher mortality.

CONCLUSIONS

Many aspects of CSS are similar in childhood and adult patients. However, pulmonary and cardiac involvement is predominant in pediatric CSS and mortality is substantial.

Differences in regulatory T cells between Churg-Strauss syndrome and chronic eosinophilic pneumonia with asthma

BACKGROUND

Chronic eosinophilic pneumonia (CEP) with asthma precedes the onset of Churg-Strauss syndrome (CSS) in half of all patients with CSS. It is not known what determines whether patients with CEP after asthma will have CSS.

OBJECTIVE

We examined whether activation of regulatory T cells in patients with CEP inhibits CSS development and is otherwise involved in the mechanism of CSS disease.

METHODS

In patients with CSS (n = 38), CEP with asthma (n = 20), and general adult asthma (n = 108), we examined the number of CD4(+)CD25(+) T cells in peripheral blood, as well as levels of expression of the cytokines IL-2, IL-5, IL-10, and TGF-beta by CD4(+)CD25(+) T cells, CD4(+)CD25(-) T cells, or both.

RESULTS

At disease onset, patients with CSS, unlike patients with CEP, had significantly fewer CD4(+)CD25(+) T cells than patients with any step of asthma. CD4(+)CD25(+) T cells producing IL-10 were rarely detected in patients with CSS at disease onset or relapse, whereas the numbers of IL-10-producing T cells in patients with CEP were high at disease onset. There were fewer CD4(+)CD25(-) T cells producing IL-2 in patients with CSS before treatment than in patients with CEP at disease onset. The proportions of CD4(+)CD25(+) T cells producing IL-10 and CD4(+)CD25(-) T cells producing IL-2 in patients with CSS increased at remission.

CONCLUSIONS

Maintenance of the numbers of regulatory T cells in patients with CEP with asthma might inhibit CSS development through the action of cytokines, such as IL-10 and IL-2, produced by CD4(+)CD25(+) or CD4(+)CD25(-) T cells. This might be part of a mechanism that influences progression and prognosis in these diseases.

[A patient with Churg-Strauss syndrome presenting as Guillain-Barré syndrome]

A 74-year-old man presented in a pulmonary clinic with symmetrically ascending tetraparesis. Physical and neurophysiological examinations suggested Guillain-Barré syndrome. The patient was treated with an initial course of 7s immunoglobulins without success. His state worsened until he was unable to walk. Severe eosinophilia (41%) was later noted in the differential white blood cell count. Combined with the onset of asthma-like symptoms, this prompted us to suspect Churg-Strauss syndrome. Despite treatment with high-dose corticoids, the palsy did not improve. It was only after immunosuppression with cyclophosphamide that the patient began to recover. The subgroup of necrotising vasculitides must be considered as differential diagnosis of rapidly progressive, symmetrical neuropathy with ascending course. Early identification and treatment are essential, since early immunosuppressive therapy is often successful, whereas delayed initiation of treatment may lead to a fatal outcome.

Clonal CD8+ TCR-Vbeta expanded populations with effector memory phenotype in Churg Strauss syndrome

Churg Strauss Syndrome (CSS) is a systemic vasculitis in which oligoclonal T cell expansions might be involved in the pathogenesis. Combined analysis of TCR-Vbeta expression profile by flow cytometry and of TCR gene rearrangement by heteroduplex PCR was used to detect and characterize T cell expansions in 8 CSS patients, 10 asthmatics and 42 healthy subjects. In all CSS patients one or two Vbeta families were expanded among CD8+ cells, with an effector memory phenotype apt to populate tissues and inflammatory sites. Heteroduplex PCR showed the presence of one or more clonal TCR rearrangements, which reveals monoclonal or oligoclonal T cells subpopulations. After purification with a Vbeta specific monoclonal antibody, each CD8+/Vbeta+ expanded family showed a single TCR rearrangement, clearly suggestive of monoclonality. All CD8+ expansions were detectable throughout the disease course. TCR-Vbeta expanded or deleted populations were not observed in asthmatic patients. Clonal CD8+/Vbeta+ T cell expansions might be useful as a disease marker.

[Churg-Strauss syndrome]

Churg-Strauss syndrome is a systemic ANCA-associated vasculitis arising almost exclusively in patients with a pre-existent asthma. Common clinical manifestations are marked blood eosinophilia, asthma, chronic sinusitis, cardiomyopathy, pulmonary infiltrates, gastrointestinal complaints and a multiplex neuropathy. The morphological substrate is an eosinophilic necrotizing vasculitis. Other eosinophilic disorders such as parasitic diseases, allergies and idiopathic hyper-eosinophilic syndrome have to be excluded. The mainstay of therapy is high-dose corticosteroids with the addition of cytotoxic drugs in patients with poor prognosis.

Renal pathology of ANCA-related vasculitis: proposal for standardization of pathological diagnosis in Japan

BACKGROUND

In Japan, systematic evaluation of the histologic parameters of anti-neutrophil cytoplasmic autoantibodies (ANCA)-related vasculitis has been performed according to the Japanese classification by Shigematsu et al. However, this classification is quite different from that of the European Vasculitis Study Group (EUVAS) classification. Therefore, a histological common basis is needed to compare Japanese histological data with the international database.

METHOD

Histological parameters concerning glomerular, tubulointerstitial, and vascular lesions of ANCA-related vasculitis, which are indispensable for clinical management, were elucidated and defined by reviewing, utilizing the merits of, and amending the two scoring systems.

RESULTS AND CONCLUSION

A new comprehensive and standardized scoring system, by which histological quantitative assessment can provide evidence for therapy planning, has been developed for renal biopsy of Japanese ANCA-related vasculitis.

A case of Churg-Strauss syndrome with refractory otitis media

OBJECTIVE

Churg-Strauss syndrome (CSS) is known as autoimmune vasculitis with peripheral eosinophilia after bronchial asthma and rarely has otological findings. We present a case of CSS with refractory otitis media and discuss the relationship between otological symptoms of CSS and eosinophilic otitis media.

CASE REPORT

A 60-year-old woman had suffered from recurrent sinusitis for 8 years, and also otitis media with effusion for 4 months. Eruption with peripheral eosinophilia was found in the lower legs; therefore, she was diagnosed with CSS. She was treated with systemic administration of prednisolone, intratympanic injection of betamethasone, and betamethasone nasal spray; thereafter, eosinophilia, otitis media and sinusitis rapidly improved.

CONCLUSION

The features of eosinophilic otitis media are similar to the otological symptoms of CSS. It should be considered whether patients with eosinophilic otitis media have early phase CSS.

Nasal polyposis in Churg-Strauss syndrome

OBJECTIVES

Churg-Strauss syndrome (CSS) is a systemic vasculitic disorder of unknown etiology that affects small-to-medium-size blood vessels. Patients affected by CSS frequently show ear, nose, and throat manifestations, which are often present at the time of disease onset. The purpose of this study was to determine the frequency of nasal polyposis in a series of 29 patients with CSS and to correlate the nasal findings to the total health situation of these patients.

STUDY DESIGN

Retrospective analysis.

SETTING

Department of Otolaryngology and Department of Clinical Medicine, Nephrology and Health Science, University of Parma.

METHODS

Twenty-nine patients with CSS were identified. Of the 29 patients, 17 (58.6%) had nasal polyposis and were enrolled in this study. The nasal polyps were graded according to the Lund and Mackay endoscopic and radiological classifications.

RESULTS

At diagnosis, endoscopic intranasal evaluation identified nasal polyposis of grade 3 in nine cases (52.9%), grade 2 in six cases (35.2%), and grade 1 in the remaining case (5.8%). After corticosteroid and immunosuppressive therapy, clinical remission was achieved in 14 patients (82.3%), whereas 3 patients experienced a relapse. Posttreatment endoscopic evaluation showed a permanent disappearance (grade 0) of nasal polyps in eight patients (47%). The other nine patients (52.92%) were found to have a small polyp situated in the middle meatus (grade 1).

CONCLUSIONS

Nasal polyposis in patients with CSS may represent the initial phase of the syndrome, though patients often have concurrent pulmonary disease. Corticosteroid therapy either alone or combined with immunosuppressive drugs usually yielded improvement or stabilization.

Intravenous immunoglobulins for relapses of systemic vasculitides associated with antineutrophil cytoplasmic autoantibodies: results of a multicenter, prospective, open-label study of twenty-two patients

OBJECTIVE

To evaluate at 9 months and 24 months the safety and efficacy of intravenous immunoglobulins (IVIGs) administered for 6 months to treat relapses of Wegener's granulomatosis (WG) or microscopic polyangiitis (MPA) occurring either under treatment or during the year following discontinuation of corticosteroids and/or immunosuppressants.

METHODS

Patients received IVIGs (0.5 gm/kg/day for 4 days) as additional therapy administered monthly for 6 months and were assessed every 3-6 months. Corticosteroids could be maintained or reintroduced at the time of relapse; immunosuppressants could be continued but could not be reintroduced. At months 9 (end point) and 24 (followup), the following information was collected: complete or partial remission, relapse as assessed with the Birmingham Vasculitis Activity Score (BVAS) 2005, and tolerance and safety of IVIG therapy.

RESULTS

Twenty-two Caucasian patients (7 men and 15 women) were studied: 19 had WG, and 3 had MPA. Their median age was 53 years (range 19-75 years), and their median duration of systemic vasculitis was 27 months (range 7-109 months). Their median BVAS 2005 score was 11 (range 3-25). At study entry, 21 patients were ANCA positive, and 21 patients were taking steroids and/or immunosuppressants. All patients experiencing relapse were treated with the same drug(s) plus IVIGs. All patients initially responded to IVIG therapy. By month 9, 13 patients had complete remission, 1 had partial remission, 7 had relapse, and 1 had treatment failure. In 8 of the 14 patients who had remission, the response persisted at month 24. Seven patients experienced minor side effects.

CONCLUSION

IVIGs induced complete remissions of relapsed ANCA-associated vasculitides in 13 of 22 patients at month 9. Because of the good safety and tolerance profiles of IVIGs, these agents can be included in a therapeutic strategy with other drugs used to treat relapses of WG or MPA.