The American College of Rheumatology 1990 criteria for the classification of Wegener's granulomatosis

Analytical and diagnostic accuracy of the EliA™ automated enzyme fluoroimmunoassay for antineutrophil cytoplasmic autoantibody detection

Anti-proteinase 3 antineutrophil cytoplasmic antibodies (PR3-ANCA) and anti-myeloperoxidase antibodies (MPO-ANCA) are considered important serological markers for several forms of idiopathic systemic vasculitis. The aim of the study was to verify the analytical and clinical performance of a new automated enzyme fluoroimmunoassay, the EliA system, for PR3-ANCA and MPO-ANCA detection.

For this purpose the sera of 52 consecutive well-defined patients with a clinical diagnosis of Wegener’s granulomatosis (WG) (n = 29) or microscopic polyangiitis (MPA) (n = 23), and 70 controls suffering from connective tissue disease (25 systemic lupus erythematosus, 25 Sjögren’s syndrome and 20 rheumatoid arthritis) were tested for PR3-ANCA and MPO-ANCA with the EliA assay (Pharmacia Diagnostics, Freiburg, Germany). For comparison purposes, the same sera were also tested by indirect immunofluorescence, another direct immunometric assay (Varelisa, Pharmacia Diagnostics) and a capture PR3-ANCA (Wieslab AB, Lund, Sweden) method.

Both the EliA PR3-ANCA and MPO-ANCA assays showed between- and within-assay precision of < 10%. The dilution test gave straight lines (r

There was a high positive correlation between the EliA and Varelisa methods for quantitative detection of MPO-ANCA levels (r

In conclusion, the EliA MPO-ANCA and PR3-ANCA methods provide good diagnostic accuracy and excellent analytical accuracy, which, in association with the practicality of the automated EliA system, make this method a useful tool for the diagnosis of ANCA-associated vasculitides.

An analysis of CTLA-4 and proinflammatory cytokine genes in Wegener's granulomatosis

OBJECTIVE

The precipitating event(s) that triggers Wegener's granulomatosis (WG) is unknown. Cytokines, costimulatory molecules, and counterregulatory molecules control the quality and intensity of immune responses. Thus, they are relevant candidates for genetic studies of immune dysregulation in WG, the pathogenesis of which may be facilitated by multiple acquired and/or inherited factors. This study was undertaken to investigate possible genetic associations of various proinflammatory cytokines and CTLA-4, a receptor for T cell inhibition, with WG.

METHODS

Using polymerase chain reaction-based DNA genotyping, we investigated the polymorphisms located in the genes encoding a variety of proinflammatory cytokines and CTLA-4 in 117 American patients with WG and 123 ethnically matched healthy controls.

RESULTS

Compared with controls, patients with WG had a significantly lower frequency of homozygosity for the shortest allele (designated allele 86) of the Ctla4 microsatellite polymorphism (AT)n located in the 3'-untranslated region (3'-UTR) of exon 3 (47.0% versus 69.9%; P = 0.0005). Significant differences between patients and controls in the allelic and genotypic frequencies of polymorphisms in the other cytokine and cytokine receptor genes studied (tumor necrosis factor alpha [TNFalpha], TNF receptor I [TNFRI], TNFRII, interleukin-1beta [IL-1beta], IL-6) were not found.

CONCLUSION

The Ctla4 (AT)n 86 allele has been previously demonstrated to be crucial for maintenance of normal levels of CTLA-4 expression and balance between T cell activation and inhibition. Our results in American patients confirm findings from a Scandinavian cohort in which a positive association between WG and longer alleles of (AT)n in the Ctla4 3'-UTR was demonstrated. Diminished frequencies of the most effective allele for CTLA-4 expression may represent a WG-related susceptibility mutation that accounts, in part, for increased T cell activation and clonal expansion in WG. Blockade of T cell costimulation using CTLA-4Ig might be a useful therapeutic intervention, providing an alternative or complementary approach to conventional treatment with immunosuppressive agents.

Test characteristics of immunofluorescence and ELISA tests in 856 consecutive patients with possible ANCA-associated conditions

OBJECTIVE

To examine the test characteristics of immunofluorescence (IF) and enzyme-linked immunosorbent assays (ELISA) in a consecutive series of patients under evaluation for anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).

METHODS

Using stored sera, we performed a cross-sectional study on 856 consecutive patients tested prospectively for ANCA by IF, Based on guidelines from the 1994 Chapel Hill Consensus Conference (CHCC), we determined each patient's underlying diagnosis by a medical records review without regard to their ANCA status (the CHCC guidelines do not require ANCA as a prerequisite for diagnosis). We grouped patients with forms of vasculitis commonly associated with ANCA into one of 4 types of AAV: Wegener's granulomatosis (n = 45), microscopic polyangiitis (n = 12), Churg-Strauss syndrome (n = 4), and pauci-immune glomerulonephritis (n = 8). We also classified patients without clinical evidence of AAV (92% of all patients tested) into 5 predefined categories of disease (including "other") and an additional category for no identifiable disease. In a blinded fashion, we then performed ELISAs on the stored serum for antibodies to proteinase-3 (PR3) and myeloperoxidase (MPO) and calculated the test characteristics for both ANCA assay techniques.

RESULTS

Sixty-nine of the 856 patients (8.1%) had clinical diagnoses of AAV based on CHCC guidelines. The positive predictive value (PPV) of ELISA for AAV was superior to that of IF, 83% versus 45%. For patients with both positive IF tests and positive ELISA tests, the PPV increased to 88%. Both IF and ELISA had high negative predictive values (97% and 96%, respectively). Positive ELISA tests were associated with higher likelihood ratios (LR) than IF (54.2 [95% CI = 26.3, 111.5] versus 9.4 [95% CI = 6.9, 12.7]). The LR of both a positive IF and a positive ELISA was 82.1 (95% CI = 33.3, 202.5).

CONCLUSIONS

Compared with IF, an ELISA test fo ANCA was associated with a substantially higher PPV and LR for AAV. This fact, combined with the greater sensitivity of IF, suggests that an effective testing strategy is to perform ELISA tests only on samples that are positive for ANCA by IF.

Severe skin ulceration associated with Wegener's granulomatosis: successful treatment with hyperbaric oxygen and prostaglandin E1

Abstract A 36-year-old woman patient with intractable skin ulcers associated with Wegener's granulomatosis was successfully cured by combination therapy with hyperbaric oxygenation therapy (HBO) and intravenous prostaglandin E1 (PGE1). Treatment for 4 months with prednisolone, intravenous PGE1, and cyclophosphamide did not result in healing of the multiple skin lesions on her legs. Repeated HBO with intravenous PGE1 therapy over 6 months resulted in a complete healing of the skin ulcers. We recommend the use of HBO combined with PGE1 for severe cutaneous lesions associated with generalized vasculitis.

IgM and IgG autoantibodies from microscopic polyangiitis patients but not those with other small- and medium-sized vessel vasculitides recognize multiple endothelial cell antigens

Using a quantitative immunoblotting technique on extracts of macrovascular and microvascular endothelial cells (EC), we analyzed serum IgM and IgG reactivities of patients with active disease fulfilling the ACR and Chapel Hill criteria for the diagnosis of polyarteritis nodosa (PAN) (n = 8), PAN related to hepatitis B virus (HBV) infection (HBV-PAN) (n = 5), Wegener's granulomatosis (n = 6), microscopic polyangiitis (MPA) (n = 18), Churg-Strauss syndrome (n = 8), and patients with chronic HBV infection without PAN (n = 5) and age- and gender-matched healthy individuals (n = 45). MPA patients' IgM bound to 200-, 105-, 80-, 65-, 45-, 35-, and 33-kDa major bands, whereas IgM from controls and other patients bound predominantly to the 65-kDa band in EC extracts. MPA patients' IgG reacted mainly with 105-, 70-, 55-, and 38-kDa protein bands, whereas IgG from controls and other patients did not. Our results provide evidence that IgM and to a lesser degree IgG from MPA patients specifically recognize multiple EC antigens.

Wegener's granulomatosis diagnosed by testicular biopsy

Urogenital involvement, other than the kidneys, is extremely rare in Wegener's granulomatosis (WG) and occurs in less than 1% of the cases. When encountered it is confined to prostate, bladder, urethra, cervix, and vagina. Granulomatous infiltration of the testis from WG has not been cited in the medical literature. We report a case of WG in a Hispanic male who presented with sensorineural hearing loss and hemoptysis. He had a pulmonary lesion and a painless right testicular mass, which was found to have necrotizing granulomas on excisional biopsy. This may be the first reported case of WG diagnosed by testicular biopsy as testicular involvement is rare in WG. We believe that the actual incidence of testicular involvement in WG may be higher as genital examination may be ignored during routine physical examinations.

Limited versus severe Wegener's granulomatosis: baseline data on patients in the Wegener's granulomatosis etanercept trial

OBJECTIVE

To report baseline data on 180 patients with Wegener's granulomatosis (WG) enrolled in the WG Etanercept Trial (WGET), and to examine demographic and clinical differences between patients with limited disease and those with severe disease.

METHODS

Definitions of limited and severe disease were agreed upon by consensus of the investigators at a pretrial meeting and were incorporated into the protocol as a stratification criterion. These data were applied prospectively to the WGET patient cohort, based on clinical features and the intention to treat patients according to disease activity. Data related to disease onset, date of diagnosis, clinical features, antineutrophil cytoplasmic antibody assays, tissue biopsy findings, and other medical history were collected on a baseline medical history form. Physician-investigators from each center participated in the development of this form, and all were certified in its use prior to the start of the trial. Selected data on patients who were screened for the trial but were not enrolled were also collected.

RESULTS

Several significant differences between the limited and severe disease subsets were observed. Patients with limited disease were nearly a decade younger at disease onset compared with patients with severe disease. Thirty-three percent of patients with severe disease were women, compared with 58% of those with limited disease. Despite their younger age at symptom onset, patients with limited disease tended to have longer disease duration, a greater likelihood of experiencing exacerbation of previous disease following a period of remission, and a higher prevalence of destructive upper respiratory tract disorders at the time of enrollment (e.g., saddle-nose deformity). Patients with limited WG were less likely than those with severe disease to have antibodies to either proteinase 3 or myeloperoxidase. Patients with severe disease had a higher likelihood of previous thyroid disease, particularly either Graves' disease or Hashimoto thyroiditis, suggesting the possibility of different pathogenetic factors within these disease subsets. Other observed differences between these subsets, such as the greater frequency of alveolar hemorrhage in the severe disease group, were related to the a priori definitions of limited and severe disease.

CONCLUSION

There are significant differences between patients with limited WG and those with severe WG with regard to sex, age, the likelihood of recurrent disease, the risk of damage in certain organ systems, and, possibly, etiologic factors. These differences (and perhaps other differences that are currently unrecognized) in patient subsets may have implications for mechanisms of pathogenesis, prognosis, response to treatment, and the design of future clinical investigations.

BPI-ANCA in transporter associated with antigen presentation (TAP) deficiency: possible role in susceptibility to Gram-negative bacterial infections

Although HLA class I expression is diminished in patients with defects in the transporter associated with antigen presentation (TAP), recurrent Gram-negative bacterial lung infections are found from childhood onwards. As MHC class II-mediated responses are normal, other mechanisms that contribute to susceptibility to infections are presumed. The bactericidal/permeability-increasing protein (BPI) is a potent neutrophil antibiotic that neutralizes endotoxin efficiently. As antineutrophil cytoplasmic autoantibodies (ANCA) against BPI were found in the majority of cystic fibrosis patients and correlate with disease severity we examined the prevalence of BPI-ANCA and their contribution to susceptibility to bacterial infections in six TAP-deficient patients. Although only two patients showed ANCA in indirect immunofluorescence, BPI-ANCA occurred in five of six patients in ELISA. Purified IgG from BPI-ANCA-positive sera (five of six) inhibited the antimicrobial function of BPI in vitro. Epitope mapping revealed binding sites not only on the C-terminal but also on the antibiotic N-terminal portion of BPI, indicating that short linear BPI peptide fragments may be long-lived enough to become immunogens. In conclusion, BPI-ANCA are associated strongly with TAP deficiency. Inhibition of the antimicrobial BPI function by BPI-ANCA demonstrates a possible mechanism of how autoantibodies may contribute to increased susceptibility for pulmonary Gram-negative bacterial infections by diminished bacterial clearance.

Ureteral stenosis as the sole manifestation of Wegener's granulomatosis

In Wegener's granulomatosis, necrotizing lesions are typically located in the upper and lower respiratory tract and kidneys, and ureteral involvement is uncommon. We report 2 cases in which intrinsic ureteral stenosis was the sole manifestation of this small-vessel vasculitis. Excisional surgery evidenced characteristic granulomatous inflammation that allowed adjuvant elective medical treatment. Urologists, nephrologists, and internists should be aware of this atypical presentation of Wegener's granulomatosis. Thorough clinical and biologic assessments are warranted in the initial workup of isolated intrinsic ureteral stenosis.

Appropriateness of autoantibody testing in clinical medicine

BACKGROUND

Pathologically expressed autoantibodies reflect ongoing immune-mediated inflammation in patients and may even be regarded as surrogate markers of disease prognosis and clinical outcome in certain clinical settings.

MATERIALS AND METHODS

The most appropriate way to decide about autoantibody testing is to set a tentative diagnosis before ordering a few clinically relevant autoantibody screening tests and then follow locally agreed rules for continued testing.

RESULTS

Different algorithms were applied considering both the possibility to obtain an initial tentative diagnosis by the clinician and another strategy to be adopted when the clinical information cannot be obtained.

CONCLUSIONS

Guidelines can only be formulated by close collaboration between clinical and laboratory experts that reach agreement on testing and reporting strategies and thereby ensure the highest possible compliance with both local and international recommendations for diagnostics.

Differences in CCR5 expression on peripheral blood CD4+CD28- T-cells and in granulomatous lesions between localized and generalized Wegener's granulomatosis

Wegener's granulomatosis (WG) is an autoimmune disease characterized by granulomatous lesions and a necrotizing vasculitis. Th1-type-cells lacking CD28 are expanded independent of age and immunosuppressive therapy in WG. To address their migratory properties of CD4(+)CD28(-) T-cells we studied the expression of the inducible inflammatory Th1-type chemokine receptor CCR5 in localized WG and generalized WG. Expansion of CD4(+)CD28(-) T-cells was more prominent in generalized WG compared to localized WG. In localized WG a larger fraction of CD4(+)CD28(-) T-cells displayed CCR5 expression compared to generalized WG. CCR5 expression was also higher in granulomatous lesions in localized WG. Higher levels of CCR5 expression on CD4(+)CD28(-) T-cells in localized WG may favor stronger CCR5-mediated recruitment of this T-cell subset into granulomatous lesions in localized WG. Expansion of Th-1-type CD4(+)CD28(-)CCR5(+) effector memory T-cells might contribute to disease progression and autoreactivity, either directly, by maintaining the inflammatory response, or as a result of bystander activation.

Clinical value of gallium-67 scintigraphy in assessment of disease activity in Wegener's granulomatosis

BACKGROUND

Diagnosis of active pulmonary and paranasal involvement in patients with Wegener's granulomatosis (WG) can be difficult. The diagnostic value of gallium-67 scintigraphy in WG is unclear.

OBJECTIVE

To evaluate the added diagnostic value of gallium-67 scintigraphy in patients with WG with suspected granulomatous inflammation in the paranasal and chest regions.

METHODS

Retrospectively, the diagnostic contribution of chest and head planar gallium scans in 40 episodes of suspected vasculitis disease activity in 28 patients with WG was evaluated. Scans were grouped into normal or increased uptake for each region. Histological proof or response to treatment was the "gold standard" for the presence of WG activity.

RESULTS

WG activity was confirmed in 8 (20%) episodes, with pulmonary locations in three, paranasal in four, and both in one (n=7 patients); all these gallium scans showed increased gallium uptake (sensitivity 100%). Gallium scans were negative for the pulmonary area in 23/36 scans (specificity 64%), and negative for paranasal activity in 13/16 scans (specificity 81%) in episodes without WG activity. Positive predictive value of WG activity for lungs and paranasal region was 24% and 63%, respectively, negative predictive value was 100% for both regions. False positive findings were caused by bacterial or viral infections.

CONCLUSION

Gallium scans are clinically helpful as a negative scan virtually excludes active WG. Gallium scintigraphy of chest and nasal region has a high sensitivity for the detection of disease activity in WG. However, because of positive scans in cases of bacterial or viral infections, specificity was lower.

A case report of wegener granulomatosis treated only with corticosteroids for 30 years

BACKGROUND

Wegener granulomatosis is a systemic vasculitis classically described as involving the upper and lower respiratory tracts together with glomerulonephritis. Its poor prognosis was marginally improved with the use of corticosteroids, and long-term remission was not achieved until the introduction of cytotoxic agents. Generalized or systemic Wegener granulomatosis has a worse prognosis than those limited to the respiratory tracts.

OBJECTIVE

To report the case of an individual who we suspect has a 30-year history of Wegener granulomatosis treated only with prednisone.

METHODS

A literature search was performed with PubMed using the keywords Wegener granulomatosis, survival, prognosis, and treatment.

RESULTS

Our patient is alive 32 years after her initial symptoms of vasculitis. She has been taking daily prednisone only for the majority of this time. Our clinical diagnosis of Wegener granulomatosis is based on the history and very high antineutrophil cytoplasmic antibody with the cytoplasmic pattern.

CONCLUSIONS

There may be variants of generalized Wegener granulomatosis that survive with less aggressive treatment.

The epidemiology of the primary systemic vasculitides in northwest Spain: implications of the Chapel Hill Consensus Conference definitions

OBJECTIVE

To assess the epidemiology of the primary systemic vasculitides (PSV) in a well-defined population of southern Europe over a 14-year period using the Chapel Hill Consensus Conference (CHCC) definitions.

METHODS

The case records of all patients 15 years or older with vasculitis diagnosed between January 1988 and December 2001 at a single reference hospital in the Lugo region of northwest Spain were reviewed. Incidence rates were age- and sex-adjusted to the European standard population. Patients were classified as having PSV according to the CHCC definitions.

RESULTS

Fifty-four Lugo residents (29 men) fulfilled the CHCC definitions for PSV. The mean age was 60.7 +/- 13.5 years (men: 61.0 +/- 13.4; women: 60.4 +/- 13.8 years). The overall annual incidence of PSV was 13.07/million (95% confidence interval [95% CI] 8.89-19.22). PSV were slightly more common in men. The age-specific incidence showed a clear increase with age. A peak in the 55-64 year age group for the whole group of patients with PSV was observed (34.9/million; 95% CI 28.6-42.6). Nonrandom periodical peaks of incidence every 3 years were only observed when the group of PSV was considered as a whole (P = 0.040). The annual incidence was 2.95/million (95% CI 1.44-6.05) for Wegener's granulomatosis (WG) and 7.91/million (95% CI 4.74-13.20) for microscopic polyangiitis (MPA) (P = 0.035). None of the patients with Churg Strauss syndrome (n = 4) lived in a rural area.

CONCLUSION

Our observations support an increasing incidence of PSV with age. In patients from northwest Spain defined by the CHCC definitions, MPA is more common than WG.

Shortening of telomeres: Evidence for replicative senescence of T cells derived from patients with Wegener's granulomatosis

BACKGROUND

Replicative senescence describes the fact that somatic cells undergo a finite and predictable number of cell divisions before entering an irreversible state of growth arrest. Progressive shortening of the telomeres, a consequence of cell division, is a reliable indicator of replicative senescence.

METHOD

We analyzed telomere length of DNA derived from T cells of patients suffering from Wegener's granulomatosis by Southern blotting. Moreover, expression of CD28, another marker for replicative senescence, was tested by cytofluorometry.

RESULTS

In patients with disease for more than 5 years, short telomeres were detected in addition to telomeres of normal length, indicating replicative senescence of discrete T-cell clones. Reduced expression of CD28 was noted, particularly on CD8-positive T cells, derived from patients with disease for more than 5 years and short telomeres.

CONCLUSION

Our data provide evidence that a portion of T cells had undergone replicative senescence, which in turn indicates clonal expansion of T cells as consequence of activation.

Staphylococcal superantigens and T cell expansions in Wegener's granulomatosis

In Wegener's granulomatosis (WG), a form of autoimmune systemic vasculitis, chronic carriage of Staphylococcus aureus constitutes a risk factor for the development of exacerbations. Circulating T cells in this disease are persistently activated, suggesting the presence of a chronic stimulus. A causal link between chronic carriage of S. aureus and chronic T cell activation in WG is conceivable, because S. aureus produces superantigens (SAg), which are potent T cell stimulators. Superantigenic stimulation of T cells results in expansion of T cell subsets expressing SAg-binding T cell receptor V-beta (Vbeta) chains. In the present study we hypothesized that in WG the presence of staphylococcal SAg is accompanied by expansion of SAg-reacting T cell subsets. We tested our hypothesis in a cross-sectional and a longitudinal study in which the association between seven staphylococcal SAg genes [typed by poplymerase chain reaction (PCR)], eight SAg-binding Vbeta chains and four SAg-non-binding Vbeta chains (assessed by flow-cytometry) was assessed. Both studies showed that T cell expansions were present at a significantly higher rate in WG patients than in healthy individuals, but were not associated with the presence of either S. aureus or its SAg. Moreover, T cell expansions were generally of small extent, and did not appear simultaneously in both CD4 and CD8 subsets. We conclude that in WG S. aureus effects its supposed pathogenic function by a mechanism other than superantigenic T cell activation.

Use of a cyclophosphamide-induction methotrexate-maintenance regimen for the treatment of Wegener's granulomatosis: extended follow-up and rate of relapse

PURPOSE

To determine the relapse rate and outcome in patients with Wegener's granulomatosis treated with daily cyclophosphamide and glucocorticoids to induce remission followed by methotrexate for remission maintenance.

METHODS

We performed an open-label prospective study in 42 patients with active Wegener's granulomatosis. All patients were treated with a standardized regimen. Outcomes were assessed using predetermined definitions based on clinical characteristics and pathologic, laboratory, and radiographic findings.

RESULTS

All patients achieved disease remission. The median time to remission was 3 months, and the median time to discontinuation of glucocorticoids was 8 months. During a median of 32 months of follow-up, 1 patient died (of a myocardial infarction not related to vasculitis). Two patients (5%) had to withdraw from the study because of medication toxicity. Twenty-two patients (52%) relapsed, with glomerulonephritis occurring in 16 patients. Of these 16 patients, 4 had an increase of >0.2 mg/dL in serum creatinine level. All 4 patients returned to their prior level of renal function with treatment. None of the 22 relapses met the criteria for severe disease.

CONCLUSION

The use of cyclophosphamide and glucocorticoids for induction and methotrexate for maintaining remission is an effective and well-tolerated therapeutic approach in patients with active Wegener's granulomatosis.

Granulomatous vasculitis

Granulomatous vasculitis is a subset of systemic necrotizing vasculitis and has granulomatous inflammation as the main histopathologic feature. Etiopathogenesis remains poorly understood, although recent advances suggest an important role for certain pro-inflammatory cytokines, such as tumor necrosis factor-alpha. They are a heterogeneous group of clinical disorders with protean manifestations. Serologic abnormalities are present, and the presence of granular cytoplasmic staining-antineutrophil cytoplasmic antibodies is most important and is particularly useful for the diagnosis of active Wegener's granulomatosis. Corticosteroids and cyclophosphamide remain very useful in the treatment of most of these disorders.

Cardiac Wegener's granulomatosis masquerading as left atrial myxoma

A 56-year-old woman was referred with mitral regurgitation, left ventricular dysfunction, and a sessile mass on the anterior leaflet of her mitral valve. The initial impression from echocardiography was that she had a left atrial myxoma. At operation, we found an intense inflammatory process diagnosed as Wegener's granulomatosis. It also involved the aortic valve and contiguous myocardium.

[Systemic necrotizing vasculitides: classifications and therapeutic strategies]

OBJECTIVES

The knowledge of systemic necrotizing vasculitides improved since new classifications have been established along with a better understanding of pathogenesis of the diseases. The major vasculitides are described herein.

CURRENT KNOWLEDGE AND KEY POINTS

Pathogenesis plays now a major role for classifying diseases and influences the diagnostic strategies. The prospective therapeutic trials established by French and European groups are largely based on our better knowledge of the diseases.

FUTURE PROSPECTS AND PROJECTS

Despite the good results obtained with and demonstrated in prospective trials, the vasculitides remain severe and deserve new studies testing new drugs but also strategies based on prognostic factors and scores which should play a major role in treatments decision.

Histologic and immunohistologic study and clinical presentation of ANCA-associated glomerulonephritis with correlation to ANCA antigen specificity

BACKGROUND

The major antigen specificities of antineutrophil cytoplasmic antibodies (ANCA) are for proteinase 3 (PR3) and myeloperoxidase (MPO). Only a limited number of studies have systematically assessed renal pathology with respect to ANCA antigen specificity.

METHODS

The authors evaluated renal biopsy light microscopy and immunofluorescence findings, clinical presentation, and outcome in 135 patients with ANCA-associated vasculitides.

RESULTS

Patients were divided into 3 groups: PR3-ANCA (n = 55), MPO-ANCA (n = 74), and ANCA of other specificities (n = 6). The mean duration of renal disease at biopsy was significantly longer in patients with MPO-ANCA than in those with PR3-ANCA (6.9 v 3.0 months). Immunofluorescence results showed mostly pauci-immune glomerulonephritis (n = 129) and rarely diffuse granular glomerular immune deposits suggesting immune complex deposition (n = 6). A focal form of crescentic glomerulonephritis was more frequent (P < 0.001), and glomerular necrosis was more prominent (P = 0.013) in the PR3-ANCA group, whereas diffuse crescentic glomerulonephritis, glomerulosclerosis, and interstitial fibrosis predominated in the MPO-ANCA group (P < 0.001). Extraglomerular vasculitis, present in 22.2%, and chronic vascular lesions indicative of previous vasculitis, present in 11.9% of patients, correlated with systemic involvement.

CONCLUSION

The evolution of the pathologic lesions of PR3-ANCA and MPO-ANCA-associated glomerulonephritis seems to be similar. Differences in histopathology could be explained by the observation that in patients with PR3-ANCA, kidney biopsy was performed soon after renal involvement appeared, and focal active lesions were prevalent, whereas in patients with MPO-ANCA, kidney biopsy was done late in the course of the disease, and diffuse chronic sclerotic lesions predominated. Renal extraglomerular small vessel vasculitis appeared to be predictive of systemic involvement.

Are environmental factors important in primary systemic vasculitis? A case-control study

OBJECTIVE

To investigate the association between primary systemic vasculitis (PSV) and environmental risk factors.

METHODS

Seventy-five PSV cases and 273 controls (220 nonvasculitis, 19 secondary vasculitis, and 34 asthma controls) were interviewed using a structured questionnaire. Factors investigated were social class, occupational and residential history, smoking, pets, allergies, vaccinations, medications, hepatitis, tuberculosis, and farm exposure in the year before symptom onset (index year). The Standard Occupational Classification 2000 and job-exposure matrices were used to assess occupational silica, solvent, and metal exposure. Stepwise multiple logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (95% CI) adjusted for potential confounders. Total PSV, subgroups (47 Wegener's granulomatosis [WG], 12 microscopic polyangiitis, 16 Churg-Strauss syndrome [CSS]), and antineutrophil cytoplasmic antibody (ANCA)-positive cases were compared with control groups.

RESULTS

Farming in the index year was significantly associated with PSV (OR 2.3 [95% CI 1.2-4.6]), with WG (2.7 [1.2-5.8]), with MPA (6.3 [1.9-21.6]), and with perinuclear ANCA (pANCA) (4.3 [1.5-12.7]). Farming during working lifetime was associated with PSV (2.2 [1.2-3.8]) and with WG (2.7 [1.3-5.7]). Significant associations were found for high occupational silica exposure in the index year (with PSV 3.0 [1.0-8.4], with CSS 5.6 [1.3-23.5], and with ANCA 4.9 [1.3-18.6]), high occupational solvent exposure in the index year (with PSV 3.4 [0.9-12.5], with WG 4.8 [1.2-19.8], and with classic ANCA [cANCA] 3.9 [1.6-9.5]), high occupational solvent exposure during working lifetime (with PSV 2.7 [1.1-6.6], with WG 3.4 [1.3-8.9], and with cANCA 3.3 [1.0-10.8]), drug allergy (with PSV 3.6 [1.8-7.0], with WG 4.0 [1.8-8.7], and with cANCA 4.7 [1.9-11.7]), and allergy overall (with PSV 2.2 [1.2-3.9], with WG 2.7 [1.4-5.7]). No other significant associations were found.

CONCLUSION

A significant association between farming and PSV has been identified for the first time. Results also support previously reported associations with silica, solvents, and allergy.

Image analysis: a novel approach for the quantification of antineutrophil cytoplasmic antibody levels in patients with Wegener's granulomatosis

Rises in antineutrophil cytoplasmic antibodies (ANCA) directed against proteinase 3 (PR3) have predictive potential for a relapse of Wegener's granulomatosis (WG). To assess the value of image analysis for monitoring ANCA levels, we measured PR3-ANCA in a cohort of PR3-ANCA positive patients with WG that were prospectively followed in our clinic and compared findings with other techniques. ANCA levels were measured serially by quantitative image analysis, titration in indirect immunofluorescence (IIF), two different directly coated antigen-specific enzyme-linked immunosorbent assays (ELISA), and a capture ELISA using a PR3-specific monoclonal antibody in 16 consecutive WG patients prior to a renal relapse, and in 16 age- and sex-matched patients with inactive WG. The positive predictive value (PPV) of an increase in ANCA titers by image analysis for relapse was 69% (11 of 16). The PPV of an increase in ANCA was 61% (11 of 18) by IIF, 71% (12 of 17) by a commercial direct ELISA, 63% (12 of 19) by in-house direct ELISA, and 75% (12 of 16) by capture ELISA. The negative predictive value (NPV) of the absence of an increase in ANCA titers by image analysis for relapse was 69% (11 of 16). The NPV of the absence of an increase in ANCA was 64% (9 of 14) by IIF, 73% (11 of 15) by a commercial direct ELISA, 63% (9 of 13) by in-house direct ELISA, and 75% (12 of 16) by capture ELISA. In conclusions, quantitative image analysis is a novel technique based on the principle of IIF to quantify ANCA levels in a single dilution in a patient sample. No major differences were observed between image analysis and the other techniques in their capacity to predict relapses of disease activity.

[Wegener's granulomatosis - a case report]

The Wegener granulomatosis (WG) is a rare vasculite which involves preferentially the upper airways, lungs and kidneys, although it can presents in a multissistemic form. The authors present a clinical case of WG, its diagnostic methodology and respective follow-up from de last two years and half. There are discussed the most often presentation forms of the disease, the importance of histologic results and the contribution of ANCA's determination for disease diagnosis and follow-up. Although important, the histological results, are not essential for WG diagnosis, since clinic presentation and immunological data (ANCA's) are suggestive of the disease. Airways infections and ANCA's presence seems to be important in the etiopathogenesis of WG.

Role of thoracic surgery and interventional bronchoscopy in Wegener's granulomatosis

BACKGROUND

Wegener's granulomatosis (WG) is defined as granulomatous vasculitis affecting small and medium-sized arteries and veins. Histologically, inflammatory changes with infiltration of the endothelium, fibrinoid necrosis, and formation of necrotizing granulomas are found. Pulmonary involvement is one of the cardinal features of WG and occurs in 85% of patients during the course of disease. Surgery is often required for both diagnosis and therapy.

METHODS

Fifteen consecutive patients are presented to illustrate the spectrum of surgical interventions in WG.

RESULTS

In 8 patients open lung biopsy, wedge resection, or segmental resection for hitherto undiagnosed infiltrate revealed WG. Eight patients presented with tracheal stenosis and all 8 underwent repetitive tracheoscopic dilation. Five patients presented with subglottic stenosis without any signs of pulmonary manifestation. All patients underwent tracheoscopic dilation, 3 in conjunction with glucocorticoid injection therapy. After multiple dilations, 1 patient still had destructing ulcerative tracheitis in which total stenting maintained airway patency. One patient received subglottic tracheal resection prior to multiple dilations; another patient, because of expiratory tracheal collapse, underwent stabilization of the membranous part of the trachea and the large bronchi with a polytetrafluoroethylene implant.

CONCLUSIONS

Surgical lung biopsy in numerous patients established the final diagnosis. Thoracic surgery including bronchologic measures such as bouginage and stenting, however, also has a place in the long-term management of WG.

Up-regulation of the dendritic cell marker CD83 on polymorphonuclear neutrophils (PMN): divergent expression in acute bacterial infections and chronic inflammatory disease

Upon cultivation with interferon-gamma (IFN-gamma ) and granulocyte/macrophage-colony stimulating factor (GM-CSF) polymorphonuclear neutrophils (PMN) acquire characteristics of dendritic cells, including expression of major histocompatibility complex (MHC) class II antigens, of the co-stimulatory antigens CD80, CD86 and of CD83, the latter considered to be specific for dendritic cells. Dendritic-like PMN were also able to present to T cells antigens in a MHC class II-restricted manner. To assess whether dendritic-like PMN are also generated in vivo, cells of patients with acute bacterial infections and of patients with chronic inflammatory diseases (primary vasculitis) were tested. During acute infection up to 80% of PMN acquired CD83, but remained negative for MHC class II, CD80 or CD86. PMN of patients with primary vasculitis expressed MHC class II antigens, CD80 and CD86, but not CD83, indicating that up-regulation of MHC class II and of CD83 are not necessarily linked to each other. Indeed, parallel studies with PMN of healthy donors showed that while IFN-gamma and granulocyte/macrophage colony stimulating factor (GM-CSF) induced both, MHC class II and CD83, tumour necrosis factor (TNF)-alpha selectively induced de novo synthesis of CD83. The function of CD83 on PMN is still elusive. A participation in the MHC class II-restricted antigen presentation could be ruled out, consistent with the segregation of MHC class II and CD83 expression. Regardless, however, of its function, CD83 expression could serve as a marker to differentiate between acute and chronic inflammation.

Intestinal Wegener's granulomatosis in a patient with severe alpha-1-antitrypsin deficiency resulting from a unique combination of two deficiency alleles (PiZ and PiMProcida)

Alpha-1-antitripsyn neutralizes the tissue damaging effects of proteases. Alpha-1-antitripsyn deficiency manifests with necrotizing vasculitis. Wegener's granulomatosis is a systemic necrotizing vasculitis that uncommonly affects the gut. The molecular genetics of patients with Wegener's granulomatosis of the gastrointestinal tract have never been characterized. A 63-year-old man with emphysema was admitted with a fever of unknown origin. Initially, this fever was linked to ileocolic Crohn's disease and later attributed to antineutrophil cytoplasm antibody-positive systemic vasculitis. Genetic analysis revealed that the alpha-1-antitripsyn deficiency was due to a previously unreported compound heterozygosity for two mutations (PiZ and PiMProcida). Our findings appear to support the concept that severe alpha-1-antitripsyn deficiency is implicated in the pathogenesis of the Crohn's disease-like milder intestinal manifestations belonging to the spectrum of Wegener's granulomatosis.

Wegener granulomatosis manifesting as meningitis. Case report

The authors describe a unique presentation of Wegener granulomatosis (WG) manifesting predominantly as meningitis. Magnetic resonance imaging demonstrated diffuse meningeal enhancement, including the pia mater, in a 28-year-old man with meningitis. A diagnosis of atypical WG was based on the findings of a dural biopsy sample and an elevated cytoplasmic antineutrophil cytoplasmic antibody (cANCA) titer, although the patient did not have any of the lesions common to WG. Immunosuppressive therapy was quite effective. With treatment, the meningeal enhancement resolved and the cANCA titer normalized. Meningeal granulomatosis as the sole lesion in WG has never been reported in the literature. This atypical course of WG should be noted.

Heterogeneity of CD4 and CD8+ memory T cells in localized and generalized Wegener's granulomatosis

Memory T cells display phenotypic heterogeneity. Surface antigens previously regarded as exclusive markers of naive T cells, such as L-selectin (CD62L), can also be detected on some memory T cells. Moreover, a fraction of CD45RO+ (positive for the short human isoform of CD45) memory T cells reverts to the CD45RA+ (positive for the long human isoform of CD45) phenotype. We analyzed patients with biopsy-proven localized Wegener's granulomatosis (WG) (n = 5), generalized WG (n = 16) and age- and sex-matched healthy controls (n = 13) to further characterize memory T cells in WG. The cell-surface expression of CD45RO, CD45RA, CD62L, CCR3, CCR5 and CXCR3 was determined on blood-derived T cells by four-color flow cytometric analysis. The fractions of CCR5+ and CCR3+ cells within the CD4+CD45RO+ and CD8+CD45RO+ memory T cell populations were significantly expanded in localized and generalized WG. The mean percentage of Th1-type CCR5 expression was higher in localized WG. Upregulated CCR5 and CCR3 expression could also be detected on a fraction of CD45RA+ T cells. CD62L expression was seen on approximately half of the memory T cell populations expressing chemokine receptors. This study demonstrates for the first time that expression of the inducible inflammatory chemokine receptors CCR5 and CCR3 on CD45RO+ memory T cells, as well as on CD45RA+ T cells ('revertants'), contributes to phenotypic heterogeneity in an autoimmune disease, namely WG. Upregulated CCR5 and CCR3 expression suggests that the cells belong to the effector memory T cell population. CCR5 and CCR3 expression on CD4+ and CD8+ memory T cells indicates a potential to respond to chemotactic gradients and might be important in T cell migration contributing to granuloma formation and vasculitis in WG.

Incidence of Henoch-Schönlein purpura, Kawasaki disease, and rare vasculitides in children of different ethnic origins

BACKGROUND

The frequency and ethnic variation of Henoch-Schönlein purpura, Kawasaki disease, and rarer vasculitides during childhood are not well characterised. Our aim was to ascertain the incidence and ethnic distribution of these conditions in children resident in a region of the UK with a diverse ethnic mix.

METHODS

1.1 million children younger than age 17 years live in the West Midlands. Between Sept 1, 1996, and Aug 31, 1999, we surveyed this population with monthly questionnaires sent to 321 consultants, a single questionnaire sent to 2860 family doctors, and review of 406 case notes with diagnostic codes for vasculitis. We included in the analyses children who fulfilled established criteria for vasculitis with disease onset during the study, and calculated incidence rates from population rates derived from the census of 1991.

FINDINGS

We identified 586 new instances of vasculitis and connective tissue disease. The estimated annual incidence of Henoch-Schönlein purpura was 20.4 per 100000, and was highest between the ages of 4 years and 6 years (70.3 per 100000). The estimated annual incidence of Kawasaki disease was 5.5 per 100000 in children younger than 5 years, and was highest in Indian subcontinent Asian children (14.6 per 100000). Indian subcontinent Asian and black children had the highest incidence of systemic lupus erythematosus, juvenile dermatomyositis, and other primary systemic vasculitides.

INTERPRETATION

Childhood Henoch-Schönlein purpura is more frequent in the West Midlands than previously reported, and Kawasaki disease has a higher incidence than previously indicated in the UK, with the highest incidence in Indian subcontinental Asian children. Other vasculitis is rare in childhood.

Vasculitis: Wegener granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, polyarteritis nodosa, and Takayasu arteritis

Identification, diagnosis, and management of the primary vasculitides and their attendant complications is a challenging task for the critical care physician. However, with appropriate therapy, the morbidity and mortality of these diseases can be markedly improved and allow the individual patient to return to their previous functional state.

Otolaryngologic manifestations of small vessel vasculitis

OBJECTIVE

The aim of the present study is to review the clinical manifestations associated with small vessel vasculitis (SVV) as they pertain to the head and neck region.

METHODS

A retrospective analysis was performed, including 34 individuals that filled the American College of Rheumatology criteria for the diagnosis of necrotizing vasculitis. Seven patients were classified as suffering from Wegener's granulomatosis (WG), 18 from microscopic polyangitis (MPA), and the remaining 19 were unclassified (unclassified small vessel vasculitis, USVV).

RESULTS

The percentage of ENT manifestations in the early clinical picture of WG patients was 86%, dropping to 44.5 and 22% for MPA and USVV patients, respectively. The overall percentage of ENT manifestations for SVV patients in their initial clinical profile was 47%.

CONCLUSION

The results of our investigation highlight the importance of an ENT clinical examination as a guide for diagnosis of an important percentage of SVV patients.

Interference of PR3-ANCA with the enzymatic activity of PR3: differences in patients during active disease or remission of Wegener's granulomatosis

Anti-neutrophil cytoplasmic antibodies (ANCA) against proteinase 3 (PR3) are strongly associated with Wegener's granulomatosis (WG) and are thought to be involved in its pathogenesis. Levels of PR3-ANCA do not always correspond to clinical disease activity. To investigate the relationship between functional effects of PR3-ANCA and disease activity, we tested the effect of IgG samples from sera of 43 WG patients, taken during active disease or remission, for their capacity to interfere with the proteolytic activity of PR3. Furthermore, longitudinal sera of seven WG patients were included. The enzymatic activity of PR3 was determined (1) with casein or with a small synthetic substrate and (2) by complexation of PR3 with alpha1-antitrypsin (alpha1-AT). With a fixed concentration (100 microg/ml) of IgG, PR3-ANCA from patients during an active phase of WG had a higher inhibitory capacity towards the proteolytic activity of PR3 and complexation of PR3 with alpha1-AT than did PR3-ANCA from WG patients during remission. However, the number of PR3-ANCA units that gave 50% inhibition of the PR3 enzymatic activity and its complexation with alpha1-AT was lower for patients during remission than for patients during an active phase of WG, indicating a stronger inhibitory capacity at a molar base. In conclusion, PR3-ANCA from patients during remission had a relatively higher inhibitory capacity towards the enzymatic activity of PR3 than PR3-ANCA from patients during an active phase. This may indicate that during active disease the ANCA titre is increased, but the number of active ANCA molecules that recognize the enzyme-inhibiting epitopes is not increased.

Wegener's granulomatosis with onset of acute pancreatitis and rapid progress. A case report

Although Wegener's granulomatosis is a rare disorder, the clinical and histological characteristics are well known. However, Wegener's granulomatosis with the onset of acute pancreatitis has rarely been reported. We discuss the case of Wegener's granulomatosis in a 65-year-old man, presenting with acute pancreatitis and whose disease progressed rapidly.

Design of the Wegener's Granulomatosis Etanercept Trial (WGET)

Wegener's granulomatosis (WG) is among the most common forms of systemic vasculitis. WG is associated with a high mortality in patients who do not receive appropriate treatment. Substantial morbidity results from standard disease therapies, however, and there is a high risk of relapse (exceeding 50%) following the taper of standard medications. The greatest challenges in the management of WG are the maintenance of disease remission and the avoidance of treatment-related morbidity and mortality. The Wegener's Granulomatosis Etanercept Trial (WGET) is a randomized, double-masked, placebo-controlled trial designed to test the ability of etanercept, a soluble inhibitor of tumor necrosis factor, to maintain disease remission when used with conventional treatments. Eight WGET clinical centers plan to enroll 180 patients over a 30-month period. The randomization is stratified by clinic and by disease severity. Patients are assigned randomly to receive etanercept or placebo in an allocation ratio of 1:1. They continue to receive standard WG therapies in regimens defined by the protocol. Upon the achievement of remission, these standard medications are tapered according to protocol guidelines. The primary outcome is sustained remission. Secondary and tertiary outcomes include a number of disease- and treatment-related measures. The trial will have a common closing date 12 months after the last patient is randomized. The primary analysis will be performed on an intention-to-treat basis. WGET is the first randomized trial in WG in the United States and the first multicenter trial of a biologic agent in WG. One year after the start of enrollment, 106 patients have been randomized. The objectives of this paper are: (1) to describe the design of the WGET; (2) to discuss issues related to the trial's development; and (3) to review some aspects of its conduct to date.

Identifying children with chronic arthritis based on chief complaints: absence of predictive value for musculoskeletal pain as an indicator of rheumatic disease in children

OBJECTIVE

To examine complaints for which children were referred to a pediatric rheumatology service and to determine whether there are specific complaints that are more likely to indicate the presence of chronic arthritis or chronic, systemic inflammatory disease.

METHODS

A retrospective chart review of 414 children referred to the pediatric rheumatology service at the Children's Hospital of Oklahoma from April 1998 to July 2001.

RESULTS

Musculoskeletal pain was the most common complaint for which children were referred (n = 226). Of these, 111 had musculoskeletal pain as an isolated complaint. One of these children had a chronic inflammatory disease. Another 115 children had pain as 1 of several reasons for seeking a rheumatology consultation, including positive results on laboratory tests (antinuclear antibody, erythrocyte sedimentation rate, and rheumatoid factor). Nineteen of these children had a chronic inflammatory disease, including 12 with juvenile rheumatoid arthritis (JRA). Thus, musculoskeletal pain as a presenting complaint had a strong negative predictive value for the presence of either JRA (0.95) or any other chronic inflammatory disease that might be characterized by arthritis. Children who were referred, in part, because of positive antinuclear antibody and/or rheumatoid factor tests were no more likely to have a chronic inflammatory disease than children who did not include such results as a reason for referral. Joint swelling, in contrast, was the most likely complaint to be associated with a diagnosis of JRA.

CONCLUSIONS

Musculoskeletal pain was the most common reason for referral to our pediatric rheumatology clinic. However, isolated musculoskeletal pain, in the absence of other signs or symptoms, is almost never a presenting complaint of children with chronic forms of arthritis. Children with arthritis more commonly present with complaints of joint swelling and/or gait disturbance. Neither ANA nor rheumatoid factor evaluations were useful in evaluating children with musculoskeletal complaints.

In vitro cytokine production and proliferation of T cells from patients with anti-proteinase 3- and antimyeloperoxidase-associated vasculitis, in response to proteinase 3 and myeloperoxidase

OBJECTIVE

To investigate in vitro proliferative responses of CD4+ T cells and generation of specific cytokines induced by stimulation of peripheral blood mononuclear cells (PBMCs) from patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis with the autoantigens proteinase 3 (PR3) and myeloperoxidase (MPO).

METHODS

PBMCs from vasculitis patients with PR3 ANCA or MPO ANCA and from healthy controls were stimulated for 7 days with PR3, MPO, or control stimuli. Proliferation of CD4+ T cells was assessed by flow cytometry, using the proliferation marker Ki-67. Levels of the pro-proliferative cytokines interleukin-2 (IL-2) and IL-6 and of the Th1 and Th2 cytokines interferon-gamma (IFN gamma) and IL-10 in culture supernatants were determined.

RESULTS

PR3 and MPO induced proliferative responses in CD4+ T cells from individual patients with ANCA-associated vasculitides and healthy controls in vitro. Neither PR3 nor MPO elicited significant IL-2 production. Levels of IL-6 were highest after stimulation with PR3 but low after stimulation with MPO, independent of study group. Stimulation with PR3, and to a lesser extent with MPO, induced a Th2 cytokine milieu, characterized by high production of IL-6 and IL-10 and low production of IFN gamma in patients and controls.

CONCLUSION

PR3 and MPO promote proliferation of CD4+ T cells from patients with ANCA-associated vasculitides, but also cross-stimulate T cells from healthy individuals. Strong IL-10 production elicited by PR3 in vitro may act as an inhibitory signal for T cell proliferation and may have an important immunoregulatory function in vivo.

C-ANCA-positive IgG fraction from patients with Wegener's granulomatosis induces lung vasculitis in rats

The aim of the present study was to analyse in rats the ability of C-ANCA-positive IgG fraction in triggering inflammatory response on pulmonary tissue. Wistar rats (n = 18) were injected via the the internal jugular vein with 20 mg of total C-ANCA-positive IgG fraction isolated from serum of three different Wegener's granulomatosis patients obtained before therapy. Similarly, control rats were treated with IgG fraction from two rheumatoid arthritis patients (n = 7), IgG from six normal human sera (n = 15) or saline (n = 18), respectively. Animals were sacrificed after 24h of injection for histological analysis of the lungs. Vasculitis and inflammatory infiltrate were consistently absent in rats injected with rheumatoid arthritis IgG or saline and in 14/15 of normal IgG treated animals. In contrast, marked vasculitis was observed in all 18 animals injected with C-ANCA-positive IgG fraction. The histological features were characterized by the presence of a perivascular pleomorphic cellular sheath, particularly around small vessels, endothelial adherence and diapedesis of polymorphonuclear leucocytes and presence of granuloma-like lesions. A dose-response relationship was observed between protein concentration of C-ANCA IgG sample and the intensity of the inflammatory response in the animals. In addition, IgG fraction with undetectable C-ANCA, obtained from one patient in remission after treatment, was not able to reproduce the pulmonary tissue alterations induced by its paired IgG that was positive for C-ANCA taken before therapy. The experimental model described herein may be useful to characterize more effectively the pathogenic mechanism of C-ANCA in Wegener's disease.

High rate of renal relapse in 71 patients with Wegener's granulomatosis under maintenance of remission with low-dose methotrexate

OBJECTIVE

To examine the long-term efficacy of low-dose intravenous methotrexate (MTX) with and without concomitant glucocorticoids (GC) for remission maintenance in patients with generalized Wegener's granulomatosis (WG) in an open-label, prospective, standardized trial.

METHODS

After induction of remission by cyclophosphamide and GC, 71 patients (41 males, 30 female) with initially generalized WG received low-dose methotrexate at 0.3 mg/kg body weight once weekly. At study-start 55 of 71 (77.5%) patients were on low-dose GC (mean 5.9 mg/day) which was tapered during the study. All patients underwent interdisciplinary staging at 3-month (and later at 6-month) intervals to assess disease activity and extent as well as side effects. End points were the first relapse or the end of study (January 2001).

RESULTS

Within a mean followup period of 25.2 months, 26 patients (36.6%) experienced a relapse after a mean of 19.4 months. Seventeen (65.4%) of these 26 patients had terminated GC therapy at the time of relapse. There was no difference in relapse rates among patients with and without concomitant GC at study start. Relapses occurred mainly in the initially involved organ systems, preferentially in the ear, nose and throat tract in 18 of 26 patients and the kidney in 16 of 26 patients. One renal relapse presented as rapid, progressive glomerulonephritis with lethal outcome. Further, 14 relapses were accompanied by a significant rise in creatinine values. In 15/26 patients the relapse was paralleled or preceded by a significant rise of antineutrophil cytoplasmic antibody titer. Two patients ceased MTX prematurely because of persistent leukopenia.

CONCLUSION

Weekly MTX is a well tolerated therapy for long-term maintenance of remission. However, one-third of the patients relapsed during ongoing MTX treatment, irrespective of whether they were still receiving GC. Because more than half of the relapses affected the kidney, close monitoring is indispensable.

Safety and efficacy of disease-modifying anti-rheumatic agents: focus on the benefits and risks of etanercept

The traditional approach to the treatment of rheumatoid arthritis (RA) has been the use of nonsteroidal anti-inflammatory drugs usually in combination with a disease-modifying antirheumatic drug (DMARD) such as hydroxychloroquine, gold, sulfasalazine, methotrexate, leflunomide or cyclosporin. Each of these DMARDs has its own distinct toxicities but has also been shown to be effective in reducing signs and symptoms of disease and to some extent, reduce radiological progression. Within the past 10 years, the combination of several traditional DMARDs has been shown to have increased efficacy over monotherapy without a significant increase in toxicity in a majority of studies. Recently, the US Food and Drug Administration has approved infliximab, a chimeric monoclonal antibody to tumour necrosis factor (TNF)-alpha in combination with methotrexate, for the treatment of signs and symptoms of RA, delay of radiological progression of disease and improvement of physical function while anakinra, an interleukin-1 receptor antagonist, has been approved for the treatment of the signs and symptoms of RA either as monotherapy or in combination with methotrexate. Etanercept is the first biological response modifier approved for use in RA in the US. Double-blind, randomised controlled studies have shown etanercept to be effective therapy in patients with RA who have had inadequate response to DMARDs, in combination with methotrexate, and as early monotherapy. Similar results were seen in juvenile and psoriatic arthritis in DMARD nonresponders. Open-label studies have shown efficacy in adult Still's disease, ankylosing spondylitis, progressive systemic sclerosis, Wegener's granulomatosis and chronic uveitis. Safety issues are a concern because of the ubiquitous role of TNF. To date the only consistent adverse event seen with etanercept has been injection site reactions. Infections occur at the same rate and with the same frequency as the placebo population. There should be caution, however, with using etanercept in patients with a serious infection, or recurrent infections or patients with untreated or latent tuberculosis. As of yet there has not been seen an increase of malignancies. Rare neurological and haematological events have been noted. Etanercept has been a significant addition to the armamentarium of medications for the treatment of RA, juvenile and psoriatic arthritis. Preliminary data show that it may be well tolerated and effective in other rheumatic diseases in which there is over production of TNFalpha.

Long distance road transport of a patient with Wegener's Granulomatosis and respiratory failure using extracorporeal membrane oxygenation

Wegener's Granulomatosis is a necrotizing vasculitis that in its most severe form can cause respiratory failure, renal failure and subglottic stenosis requiring surgical airway access. We describe the use of portable extracorporeal membrane oxygenation and the long distance road transport of a patient with Wegener's Granulomatosis who developed respiratory failure that was refractory to conventional mechanical ventilation. We have demonstrated the effective use of portable extracorporeal membrane oxygenation for stabilization and safe acute interhospital transfer over a long distance by road ambulance to a tertiary centre for further management.

Pulmonary eosinophilic vasculitis in a neonate with congenital chylothorax

We report a case of congenital bilateral chylothorax, complicated by pulmonary eosinophilic vasculitis and transient eosinophilia. Excluding all known forms of eosinophilic pulmonary disease either histologically or clinically, possible mechanisms of its etiology are discussed. Treatment with corticosteroids was successful, and after a prolonged clinical course the patient recovered by age 2 years.

Expression of recombinant proteinase 3, the autoantigen in Wegener's granulomatosis, in insect cells

Proteinase 3 (PR3) is the major autoantigen for anti-neutrophil cytoplasmic antibodies (ANCA) in patients with Wegener's granulomatosis. Little is known about the major antigenic sites on PR3. To facilitate epitope mapping, PR3 was cloned in insect cells using a baculovirus expression system. Four different sequences of the PR3 cDNA were amplified by PCR: two clones containing the pro-peptide of PR3 with or without a His-tag (rproPR3-his and rproPR3, respectively) and two clones without the pro-peptide and with or without a His-tag (rPR3-his and rPR3, respectively). The PR3 sequences were cloned behind the polyhedrin promoter and the honeybee melittin signal peptide enabling secretion of rPR3. Plasmids were transposed into the genome of baculovirus, and wild types as well as PR3-containing virus genomes were transfected into Sf21 insect cells. All four rPR3 variants were secreted into the medium and were recognized by anti-neutrophil PR3 rabbit serum and by at least two anti-PR3 monoclonal antibodies. Mature forms of PR3 were recognized by almost all patient sera, whereas the pro-forms of PR3 were recognized by 14 of 18 PR3-ANCA sera tested. On SDS-PAGE, the four rPR3 forms migrated at approximately 32 kDa. RPR3-his and rproPR3-his could be purified by means of this His-tag. In conclusion, especially the mature rPR3s are well recognized by PR3-ANCA sera. The presence of a C-terminal His-tag facilitated purification of His-tagged rPR3. Thus, rPR3 expressed in insect cells can be used as a tool for diagnostic tests as well as for epitope mapping studies.

Detection of anti-neutrophil cytoplasmic antibodies under actual clinical testing conditions

Anti-neutrophil cytoplasmic antibodies (ANCA) are a useful diagnostic tool for Wegener's granulomatosis (WG) and microscopic polyangiitis (MPA). To maximize diagnostic utility, current guidelines recommend dual testing by standard indirect immunofluorescence (IIF) and target antigen-specific assays. Most published data come from specialized research laboratories, not reflecting the performance of assays under routine clinical conditions. Therefore, we compared the performance of standard IIF, PR3-, and MPO-ANCA-specific direct ELISA, and a PR3-ANCA-specific capture ELISA used alone and in combination under routine clinical conditions. Consecutive serum samples (615) submitted for routine ANCA testing over a 10-month period were assayed. Diagnoses were WG/MPA (n = 86), other autoimmune disease (n = 118), and various others (n = 411). The combination of PR3-ANCA and MPO-ANCA ELISA had the highest sensitivity (72.1%), and C-ANCA determination using IIF, the highest specificity (99.6%). While maintaining maximal diagnostic accuracy, significant labor savings are achieved by screening for WG/MPA by ELISA followed by confirmatory IIF.