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

Carbimazole induced eosinophilic granulomatous vasculitis localized to the stomach

Vasculitis associated with anti-neutrophil cytoplasmic antibodies has been reported in patients treated with anti-thyroid drugs and especially propylthiouracil. We report here a case of granulomatous eosinophilic vasculitis mimicking gastric neoplasm and peripheral eosinophilia in a 27-year-old man who was treated with carbimazole for 5 months for Graves' disease. Clinical and morphologic features resolved within 2 months after stopping the drug, suggesting a causative role for the drug. To our knowledge, this is the first biopsy-proven granulomatous eosinophilic vasculitis associated with this drug.

The wide spectrum of clinical manifestations in Sjögren's syndrome-associated neuropathy

We assessed the clinicopathological features of 92 patients with primary Sjögren's syndrome-associated neuropathy (76 women, 16 men, 54.7 years, age at onset). The majority of patients (93%) were diagnosed with Sjögren's syndrome after neuropathic symptoms appeared. We classified these patients into seven forms of neuropathy: sensory ataxic neuropathy (n = 36), painful sensory neuropathy without sensory ataxia (n = 18), multiple mononeuropathy (n = 11), multiple cranial neuropathy (n = 5), trigeminal neuropathy (n = 15), autonomic neuropathy (n = 3) and radiculoneuropathy (n = 4), based on the predominant neuropathic symptoms. Acute or subacute onset was seen more frequently in multiple mononeuropathy and multiple cranial neuropathy, whereas chronic progression was predominant in other forms of neuropathy. Sensory symptoms without substantial motor involvement were seen predominantly in sensory ataxic, painful sensory, trigeminal and autonomic neuropathy, although the affected sensory modalities and distribution pattern varied. In contrast, motor weakness and muscle atrophy were observed in multiple mononeuropathy, multiple cranial neuropathy and radiculoneuropathy. Autonomic symptoms were often seen in all forms of neuropathy. Abnormal pupils and orthostatic hypotension were particularly frequent in sensory ataxic, painful, trigeminal and autonomic neuropathy. Unelicited somatosensory evoked potentials and spinal cord posterior column abnormalities in MRI were observed in sensory ataxic, painful and autonomic neuropathy. Sural nerve biopsy specimens (n = 55) revealed variable degrees of axon loss. Predominantly large fibre loss was observed in sensory ataxic neuropathy, whereas predominantly small fibre loss occurred in painful sensory neuropathy. Angiitis and perivascular cell invasion were seen most frequently in multiple mononeuropathy, followed by sensory ataxic neuropathy. The autopsy findings of one patient with sensory ataxic neuropathy showed severe large sensory neuron loss paralleling to dorsal root and posterior column involvement of the spinal cord, and severe sympathetic neuron loss. Degrees of neuron loss in the dorsal and sympathetic ganglion corresponded to segmental distribution of sensory and sweating impairment. Multifocal T-cell invasion was seen in the dorsal root and sympathetic ganglion, perineurial space and vessel walls in the nerve trunks. Differential therapeutic responses for corticosteroids and IVIg were seen among the neuropathic forms. These clinicopathological observations suggest that sensory ataxic, painful and perhaps trigeminal neuropathy are related to ganglioneuronopathic process, whereas multiple mononeuropathy and multiple cranial neuropathy would be more closely associated with vasculitic process.

Síndrome de Churg-Strauss

A síndrome de Churg-Strauss caracteriza-se por asma, eosinofilia e graus variados de vasculite sistêmica. As formas mais graves com acometimento cardíaco, gastrintestinal, sistema nervoso central e renal requerem ciclofosfamida para seu tratamento.

Eosinophilic pneumonias

Eosinophilic pneumonias (EP) encompass a wide spectrum of lung diseases characterized by peripheral blood eosinophilia (>1 x 10(9) eosinophils/l) and/or alveolar eosinophilia (>25%). Blood eosinophilia may be lacking, as in the early phase of idiopathic acute EP, or in patients already taking oral corticosteroids. EP may present with varying severity, ranging from almost asymptomatic infiltrates to the acute respiratory distress syndrome necessitating mechanical ventilation. Possible causes of EP must be thoroughly investigated, especially drugs and the variety of parasitic infections (considering history of travel or residence in areas of endemic parasitic infection). However, chronic EP remains idiopathic in many cases. When present, extrathoracic manifestations lead to suspect Churg-Strauss syndrome (CSS) or the hypereosinophilic syndrome (HES), the prognosis of which is dominated by cardiac involvement. Apart from the treatment of specific causes when possible, corticosteroids remain the cornerstone of symptomatic treatment for eosinophilic disorders, usually with a dramatic response, but frequent relapses when tapering or after stopping the treatment. The adjunction of immunosuppressants to corticosteroids is necessary in patients with CSS and poor prognosis factors. Imatinib has recently proven effective in the treatment of the myeloproliferative variant of the HES.

Wegener's granulomatosis with eosinophilia

Wegener's granulomatosis with eosinophilia both in blood and tissue samples has been rarely reported. A 25-year-old woman developed fever, granulomatous inflammation of nasal mucosa, pulmonary hemorrhage, suprascleritis, and cutaneous vasculitis. She showed eosinophilia in blood and biospy samples of skin, nasal mucosa, and lung. She was positive for proteinase 3-antineutrophil cytoplasmic antibody. She had no history of asthma. We diagnosed her as Wegener's granulomatosis with eosinophilia rather than Churg-Strauss syndrome. Her mucocutaneous and pulmonary lesions were successfully treated with high-dose corticosteroid and methotrexate, but her suprascleritis required pulsed cyclophosphamide.

Vasculites pulmonares: quando suspeitar e como fazer o diagnóstico

As vasculites pulmonares primárias são caracterizadas por processo inflamatório na parede dos vasos pulmonares que leva a isquemia e hemorragia pulmonar com as conseqüentes expressões clínicas e radiológicas. As vasculites pulmonares primárias são acompanhadas de expressão sistêmicas cutâneas, em nervos periféricos, rins, seios da face, olhos e ouvidos, além do trato gastrintestinal, e sistemas cardíaco e nervoso central. O diagnóstico é feito através da associação das informações clínicas, radiológicas e anatomopatológicas. O tratamento com corticosteróides e imunossupressores deve ser instituído precocemente e apresenta altas taxas de remissão.

Response of Vasculitic Peripheral Neuropathy to Intravenous Immunoglobulin

Peripheral neuropathy is a prominent feature of the systemic and secondary vasculitides. Usually, it responds to corticosteroids therapy, but in certain cases it may resist corticosteroid or immunosuppressive treatment, or both. The objective of this study is to present case reports of patients who exhibited various inflammatory diseases, accompanied with vasculitic peripheral neuropathies, for which intravenous immunoglobulin (IVIg) was used for treatment. The study included 10 patients with the following: Sjögren's syndrome (1), systemic lupus erythematosus (2), vaccination-induced vasculitis (1), Churg-Strauss vasculitis (1), mixed cryoglobulinemia (2), polyarteritis nodosa (1), sarcoidosis (1), and scleroderma (1). All developed vasculitic peripheral neuropathy and were treated with 1-13 cycles of high-dose IVIg (2 g/kg body weight). The patients were followed up for 1-5 years after this treatment. Results showed that in all but two patients (mixed cryoglobulinemia associated with hepatitis C and sarcoidosis), neuropathy improved or completely resolved after IVIg treatment. In conclusion, IVIg may be beneficial in cases of resistant vasculitic peripheral neuropathy. IVIg should probably be considered as a sole or adjuvant treatment in patients for whom conventional treatment is contraindicated, or for patients in whom conventional treatment has failed.

The linkage between Churg-Strauss syndrome and leukotriene receptor antagonists: fact or fiction?

Epidemiologic evidence has shown that the worldwide prevalence of asthma is increasing. The leukotriene receptor antagonists (LTRAs) represent a new class of therapy for asthma. They have been developed in the last decade and play a pivotal steroid-sparing role in treating the inflammatory component of asthma. Consequently, reports of Churg-Strauss syndrome (CSS), a rare form of systemic vasculitis, have been recognized as a potential side effect in individuals with moderate to severe asthma on LTRA therapy. The serious nature of this disorder is worthy of prompt recognition by clinicians and aggressive therapy to avoid the subsequent longstanding effects of vasculitis. To validate the postulated linkage between the LTRAs and CSS, this review comprehensively evaluates reported cases in the literature and supports a pathophysiological relationship between the LTRAs and the development of CSS.

Value of a New Automated Fluorescence Immunoassay (EliA) for PR3 and MPO-ANCA in Monitoring Disease Activity in ANCA-Associated Systemic Vasculitis

The value of anti-neutrophil cytoplasmic antibody (ANCA) detection for monitoring disease activity in ANCA-associated systemic vasculitis (AASV) remains controversial. The aim of our work was to rate the performance of a new automated fluorescence PR3 and MPO-ANCA immunoassay (EliA) for monitoring disease activity in AASV. We evaluated 100 serum samples from 71 AASV patients (with Wegener's granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome) as well as sera from 58 pathological and 35 normal controls. In addition to PR3 and MPO-ANCA EliA, we performed indirect immunofluorescence and "homemade" PR3 and MPO-ANCA ELISA tests. In AASV patients, ANCA levels were correlated with disease activity, according to the Birmingham Vasculitis Activity Score (BVAS). We derived cutoff limits from receiver operating characteristic (ROC) curve analysis comparing AASV with pathological controls. Our results showed that EliA and ELISA had comparable sensitivity (76%) and specificity (95%). The analysis of active versus inactive status and correlation with ANCA levels showed a clear difference between BVAS Group I (score < or = 4) and BVAS Group II (scores > 4) (AUC = 0.86 vs. 0.72; relative risk [RR] = 2.4; P < 0.0001) for PR3-ANCA, but not for MPO-ANCA (AUC = 0.94 vs. 0.87; RR = 1.48; P = 0.46). Serial serum samples from 16 patients were examined in detail. For the majority of patients, for both PR3 and MPO-ANCA, change in titer was strongly associated with change in BVAS score. Our data showed a good correlation between ANCA titer (especially for PR3) and AASV disease activity. We recommend that ANCA titer be used to monitor AASV disease activity with the caveat that a few exceptions, in particular with MPO-ANCA, are possible.

Isolated oculomotor nerve palsy in Churg-Strauss syndrome

A 30-year-old man with bronchial asthma complained of horizontal diplopia. Partial oculomotor nerve palsy with restrictions of elevation and adduction, and mydriasis was observed in the left eye. Cranial magnetic resonance imaging demonstrated an infarct lesion in the territory of the left superior median mesencephalic branch of the posterior cerebral artery. Based on bronchial asthma, hypereosinophilia, mononeuropathy multiplex, pulmonary eosinophilia and positive perinuclear antineutrophil cytoplasmic antibody in the serum, the patient was diagnosed as having Churg-Strauss syndrome. This is the first case of oculomotor nerve palsy due to midbrain infarction associated with Churg-Strauss syndrome.

An autopsy case of isolated eosinophilic coronary periarteritis: a limited form of Churg-Strauss syndrome or a new entity?

A 52-year-old man without a history of asthma or allergic diseases died of ventricular fibrillation early in the morning. His autopsy revealed no significant findings, except for a mild mural-thickening localized at the proximal region of the right coronary artery. Microscopic examination showed periarteritis with infiltration of numerous eosinophils in the adventitia. No significant vasculitis was found in any other organs. Based on the findings this seems to be the second reported case of isolated eosinophilic coronary periarteritis.

Churg-Strauss syndrome associated with hypersensitivity to acetaminophen

Acetaminophen is a widely used antipyretic drug. We describe a 64-year-old Japanese woman who developed typical Churg-Strauss syndrome after frequent use of acetaminophen. Following the ingestion of acetaminophen, she exhibited various allergic reactions such as asthmatic attacks, pyrexia and petechiae on legs. In the lymphocyte transformation test, a positive reaction to acetaminophen was detected. A muscle biopsy revealed massive extravascular eosinophil infiltration and a necrotizing vasculitis. Hypersensitivity to acetaminophen may be implicated in the development of Churg-Strauss syndrome in this case.

Life-threatening purpura and vasculitis

Palpable purpura, the inflammation of blood vessels is the hallmark of vasculitis. It can be observed in a variety of settings, where vessels can be affected primarily or as a secondary event. Every patient with vasculitis should be considered to have a systemic disease unless proven otherwise. One or more systemic symptoms occur in at least 50% of patients and there is no way to predict systemic involvement. Patients may demonstrate mild systemic involvement like arthralgia and arthritis, fever and malaise or more severe symptoms such as massive proteinuria and raised creatinine leading to chronic renal failure, severe intestinal bleeding or perforation with a fatal outcome. In this article we will review the life-threatening aspects of purpura and vasculitis.

Vasculitis in the gastrointestinal tract

The primary systemic vasculitides are a rare group of inflammatory disorders, where damage is directed against the blood vessels. They range in severity from acute self-limiting illness to chronic life and organ threatening diseases requiring long-term treatment with toxic immunosuppressive regimes. None of them have specific tests and few have hard diagnostic criteria. This review summarises the gastrointestinal features of these diseases, along with their general clinical and epidemiological features and the evidence available to guide in their management.

Classification and diagnostic criteria in systemic vasculitis

Approximately 20 different primary forms of vasculitis are recognized, not all of which have been included in classification schemes or consensus statements regarding nomenclature. A variety of classification schemes have been proposed over the past 50 years, many predicated upon the size of the primary type of vessel involved in a given disease, as well as other considerations that include demographic features, organ tropism, the presence or absence of granulomatous inflammation, the role of immune complexes in pathophysiology and the association of autoantibodies with some forms of vasculitis. All classification schemes to date have had shortcomings owing to the substantial gaps in knowledge about vasculitis, but the American College of Rheumatology criteria for the classification of some forms of vasculitis are useful for the purpose of including patients in research studies. The Chapel Hill Consensus Conference has clarified some existing controversies in nomenclature of the systemic vasculitides. Robust diagnostic criteria for the various forms of vasculitis have, however, remained elusive.

Peripheral neuropathy in systemic vasculitides

PURPOSE OF REVIEW

Peripheral nervous system (PNS) involvement is of great diagnostic value in systemic vasculitides, because it occurs frequently and often early during the course of these diseases, despite the supposed blood-nerve barrier that should prevent or at least minimize PNS damage. However, it carries no poor prognostic value in vasculitides. Recent advances have been made in understanding the pathogenetic mechanisms of PNS involvement.

RECENT FINDINGS

Vasculitic neuropathy may result from primary or secondary systemic vasculitides, or may be restricted to the PNS, in a form that is now also considered to be a systemic vasculitis. The blood-nerve barrier is not as efficient as the blood-brain barrier. Inflammatory cell infiltration into the vasa nervorum and epineurial arteries leads to ischemic axonal nerve injury and is facilitated by additional breaches in the blood-nerve barrier, induced by proinflammatory cytokines, oxidative stress-derived molecules, and matrix metalloproteinases. Although animal models of myeloperoxidase or, now, proteinase 3-antineutrophil cytoplasmic autoantibody-inducing vasculitis have been developed, they do not support a role for antineutrophil cytoplasmic autoantibodies in PNS involvement. Treatment should be chosen based on the other organ involvement and the patient's general condition. When PNS involvement is isolated, corticosteroids alone should be used as first-line treatment.

SUMMARY

Apart from the so-called nonsystemic nerve vasculitis, PNS involvement is rarely the sole clinical sign of systemic necrotizing vasculitis, and its association with other typical manifestations is often suggestive of the diagnosis of vasculitis. Herein are summarized recent advances that have clarified but not yet fully elucidated the pathogenesis of peripheral neuropathy in systemic vasculitides, together with the latest clinical findings and therapeutic strategies.

Presentation and outcome of gastrointestinal involvement in systemic necrotizing vasculitides: analysis of 62 patients with polyarteritis nodosa, microscopic polyangiitis, Wegener granulomatosis, Churg-Strauss syndrome, or rheumatoid arthritis-associated vasculitis

We reviewed the medical records of 62 patients with systemic small and medium-sized vessel vasculitides and gastrointestinal tract involvement followed at our institution between 1981 and 2002. This group included 46 men and 16 women (male:female ratio, 2.9), with a mean age of 48 +/- 18 years. Vasculitides were distributed as follows: 38 polyarteritis nodosa (21 related to hepatitis B virus), 11 Churg-Strauss syndrome, 6 Wegener granulomatosis, 4 microscopic polyangiitis, and 3 rheumatoid arthritis-associated vasculitis. Gastrointestinal manifestations were present at or occurred within 3 months of diagnosis in 50 (81%) patients and were mainly abdominal pain in 61 (97%), nausea or vomiting in 21 (34%), diarrhea in 17 (27%), hematochezia or melena in 10 (16%), and hematemesis in 4 (6%). Gastroduodenal ulcerations were detected endoscopically in 17 (27 %) patients, esophageal in 7 (11%), and colorectal in 6 (10%), but histologic signs of vasculitis were found in only 3 colon biopsies. Twenty-one (34%) patients had a surgical abdomen; 11 (18%) developed peritonitis, 9 (15%) had bowel perforations, 10 (16%) bowel ischemia/infarction, 4 (6%) intestinal occlusion, 6 (10%) acute appendicitis, 5 (8%) cholecystitis, and 3 (5%) acute pancreatitis. (Some patients had more than 1 condition.) Sixteen (26%) patients died.The respective 10-month and 5-year survival rates were 71% (95% confidence interval [CI], 52-90) and 56% (95% CI, 35-77) for the 21 surgical patients; and 94% (95% CI, 87-101) and 82% (95% CI, 70-94) for the 41 patients without surgical abdomen (p = 0.08). Peritonitis (hazard ratio [HR] = 4.3, p < 0.01), bowel perforations (HR = 5.7, p < 0.01), gastrointestinal ischemia or infarctions (HR = 4.1, p < 0.01), and intestinal occlusion (HR = 5.5, p < 0.01) were the only gastrointestinal manifestations significantly associated with increased mortality in multivariate analysis. For this subgroup of 15 patients, 6-month and 5-year survival rates were 60% (95% CI, 35-85) and 46% (95% CI, 19-73), respectively (p = 0.003). None of the other gastrointestinal or extraintestinal vasculitis-related symptoms, or angiographic abnormalities (seen in 67% of the 39 patients who underwent angiography), was predictive of surgical complications or poor outcome. However, prognosis has dramatically improved during the past 30 years, probably owing to better management of these more severely ill patients, with prompt surgical intervention when indicated, and the combined use of steroids and immunosuppressants.

Primary systemic vasculitis: clinical features and mortality

BACKGROUND

Wegener's granulomatosis (WG), Churg Strauss syndrome (CSS) and microscopic polyangiitis (MPA) are primary systemic vasculitides (PSV), the clinical features of which have been described from tertiary centres.

AIM

To provide the first clinical description of MPA from a general hospital and compare clinical features with WG and CSS.

DESIGN

Retrospective analysis of patient records.

METHODS

Records of 99 PSV patients attending a single hospital, from 1988 to 2000, were reviewed for: clinical features, date/age at diagnosis, sex, duration of illness, anti-neutrophil cytoplasmic antibodies (ANCA), treatment, comorbidity and deaths. Cases were classified using ACR, CHCC and Lanham criteria/definitions. Birmingham vasculitis activity scores (BVAS) and damage index (VDI) were calculated. Survival was assessed using Cox proportional hazards model and standardized mortality ratios (SMRs).

RESULTS

Compared to previous reports there was more ENT (29%) and respiratory (29%) but less renal (92%) involvement in MPA, and less ENT involvement in WG (81%). CSS showed high neurological (72%), cardiovascular (28%) and gastrointestinal (17%) involvement and the highest median (range) VDI (p = 0.01 vs. WG; p = 0.001 vs. MPA). BVAS1 was significantly lower in MPA than in WG [median (range) 15 (4-29) vs. 21 (6-39), (p = 0.001)] but not in CSS [20 (7-28), p = 0.08]. SMR (95%CI) for PSV was 4.8 (3.0-6.6); 5-year survival was 45.1% for MPA, 75.9% for WG and 68.1% for CSS. Age was a significant risk, but only to the same extent as in the reference population. When age was adjusted for, no other significant factor was found.

DISCUSSION

The clinical characteristics seen here are similar to those in previous series. There are difficulties in using the MPA CHCC definitions in classification. There is a high proportion of neurological involvement in CSS, causing permanent damage. MPA may have a poorer prognosis than WG or CSS.

Multiple perforating and non perforating pilomatricomas in a patient with Churg-Strauss syndrome and Rubinstein-Taybi syndrome

We report an unusual association of multiple perforating and non-perforating pilomatricomas with Churg-Strauss syndrome, and a dysmorphic syndrome evocative of Rubinstein-Taybi syndrome. These syndromes may be independent, but these rare diseases and genetic abnormalities may be linked together.

A limited form of Churg-Strauss syndrome presenting without asthma and eosinophilia

We report a young woman presenting with digital gangrene, paranasal sinusitis, mononeuritis multiplex, and rapidly progressive glomerulonephritis without asthma and eosinophilia - an extremely rare variant of this disease.

Churg-Strauss syndrome and the leukotriene receptor antagonist pranlukast

The authors studied eight cases of Churg-Strauss syndrome (CSS) associated with the use of pranlukast, a common cysteinyl leukotriene receptor antagonist (LTRA) in Japan. The patients who received pranlukast showed significantly increased peripheral blood eosinophil count, neurological disability scores, and poor responses to corticosteroid in comparison with those patients not receiving pranlukast. We suggest that preceding administration of pranlukast aggravates clinical presentations of CSS.

Urinary eicosanoid and tyrosine derivative concentrations in patients with vasculitides

BACKGROUND

Vasculitides are classified on the basis of the type of cell involved, namely, eosinophilic vasculitides such as Churg-Strauss syndrome (CSS) and noneosinophilic vasculitides. However, knowledge on inflammatory mediators and oxidative tissue damage associated with vasculitides is insufficient.

OBJECTIVE

We measured the urinary concentrations of inflammatory mediators and tyrosine derivatives to assess biomarkers associated with the pathophysiology of vasculitides.

METHODS

Urine was collected from 9 patients with CSS during acute exacerbation and during clinical remission, 24 patients with rheumatoid arthritis in stable condition, and 8 patients with vasculitis diseases (VDs) during acute exacerbation. Leukotriene E 4 (LTE 4 ), 9alpha,11beta prostaglandin F 2 , and eosinophil-derived neurotoxin (EDN) concentrations were determined by enzyme immunoassay. 3-Bromotyrosine (BrY) and 3-chlorotyrosine (ClY) concentrations were determined by gas chromatography-mass spectrometry.

RESULTS

The urinary LTE 4 , EDN, BrY, and ClY concentrations were significantly higher in the patients with CSS during acute exacerbation than in healthy control subjects and, except for urinary ClY concentration, significantly decreased during clinical remission. The urinary EDN and BrY concentrations were significantly higher in patients with CSS during acute exacerbation than in patients with VD during acute exacerbation. Only urinary LTE 4 concentration was significantly different between the patients with rheumatoid arthritis in stable condition and the patients with VD during acute exacerbation.

CONCLUSION

Oxidative tissue damage caused by eosinophil peroxidase is a pathophysiological characteristic of eosinophil-associated diseases such as CSS. Urinary LTE 4 concentration may reflect a pathophysiological event involved in eosinophilic and noneosinophilic vasculitides. Cysteinyl-leukotriene pathways are potential therapeutic targets for small-vessel vasculitides.

Long term effectiveness of intravenous immunoglobulin in Churg-Strauss syndrome

OBJECTIVE

To study the long term effectiveness of intravenous immunoglobulin and plasmapheresis associated with prednisone and cyclophosphamide in Churg-Strauss syndrome.

SUBJECTS

and methods: We studied 18 subjects with new onset Churg-Strauss syndrome. All received the "standard" treatment based on prednisone (1 mg/kg/day for 1 month and then slowly tapered) and cyclophosphamide (2 mg/kg/day for 6 months in severe cases). In nine patients, synchronised cycles with plasmapheresis and intravenous immunoglobulin (2 g/kg) were repeated monthly for 6 months and every other month for a further three cycles. Clinical (disease activity monitored by Birmingham vasculitis activity score (BVAS) and damage index (modified Rankin score)) and functional (C reactive protein, blood eosinophil count, and electromyogram-electoneurogram) parameters were collected during treatment and the 3 year follow up period.

RESULTS

After 12 months, all patients in the treatment group and four (44%) in the control group were in remission. At the end of the 3 year follow up period, we documented significant differences in BVAS (p<0.01), global damage (p<0.02), modified Rankin score (p<0.04), and the daily maintenance prednisone dose (p<0.002) between the two groups. We found a tendency towards lower frequency of relapse and incidence of osteoporosis in the treatment group.

CONCLUSION

Complete clinical and functional recovery with a long term stable remission and a low incidence of side effects can be achieved by intravenous immunoglobulin associated with plasmapheresis in patients with Churg-Strauss syndrome.

Churg-Strauss syndrome in a case of eosinophilia

A number of allergic, infectious and idiopathic diseases are associated with an increased number of eosinophils in blood. We report the case of a woman who was referred to our outpatient clinic due to asthma that had first developed three months previously and papular rash. Laboratory investigations revealed eosinophilia (23 %; 2,162 cells/ml). An allergic cause was ruled out by anamnesis, skin prick-test and specific IgE determination. Another frequent cause of eosinophilia is infestation by parasitic helminths, but serologic studies and studies of parasites in feces were negative. Chest radiography and computed tomography scan revealed diffuse infiltrates. The diagnosis was confirmed by transbronchial and skin lesion biopsies. The patient was finally diagnosed with Churg-Strauss syndrome and was treated with oral corticosteroids. A delay in the diagnosis and treatment of this syndrome increases the risk of death from the complications of vasculitis. Because of the importance of an early diagnosis in this disease, its presence should be suspected in cases of eosinophilia after ruling out more frequent causes.

Purpura fulminans -- a novel presentation of Churg Strauss syndrome

Purpura fulminans is a rare syndrome of haemorrhagic necrosis of the skin and intravascular thrombosis associated with disseminated intravascular coagulopathy. It has not previously been reported as a presenting feature of Churg Strauss syndrome.

Clinical review: Vasculitis on the intensive care unit--part 1: diagnosis

The first part of this review addresses the diagnosis and differential diagnosis of the primary vasculitides Wegener's granulomatosis, microscopic polyangiitis, Churg–Strauss syndrome and polyarteritis nodosa. Prompt diagnosis and treatment of these conditions ensures an optimal prognosis. The development of assays for antineutrophil cytoplasmic antibodies has aided the diagnosis of Wegener's granulomatosis and microscopic polyangiitis. However, even in cases where there is high clinical likelihood that these conditions are present, up to 20% may be antibody negative, whereas alternative diagnoses may be antibody positive. The final diagnosis rests on a balance of clinical, laboratory, radiological and histological features. The exclusion of alternative diagnoses is important in assuring appropriate therapy. Particular attention is paid to the more fulminant presentations of these conditions and the role of the critical care physician in their diagnosis and management.

Prevalence of Churg-Strauss syndrome, vasculitis, eosinophilia and associated conditions: retrospective analysis of 58 prescription-event monitoring cohort studies

PURPOSE

Churg-Strauss syndrome is characterised by hypereosinophilia, systemic vasculitis and asthma. The cause is usually unknown, but there have been reports of an association with particular drugs, including anti-asthma drugs. Our aim was to estimate the prevalence of Churg-Strauss syndrome and related conditions in post-marketing safety studies of new anti-asthma drugs.

METHODS

We accessed the prescription-event monitoring (PEM) database of the Drug Safety Research Unit (DSRU). This database currently has information on 622 294 patients observed during 58 completed PEM studies of individual drugs, including 35 799 patients in studies of new anti-asthma drugs.

RESULTS

Overall, four cases of Churg-Strauss syndrome were identified during these studies, giving a period prevalence rate of 6.8 (95% confidence limits [CL]: 1.8-17.3) per million patient-years of observation. The period prevalence of Churg-Strauss syndrome was significantly greater in the PEM cohorts of anti-asthma drugs (64.4 million patient-years of observation; 95% CL: 13.3-188.1), than the other PEM drug cohorts (1.8 per million patient-years of observation; 95% CL: 0.05-10.2) (rate ratio: 35.1; 95% CL: 2.8-1839.9; p=0.002).

CONCLUSION

Our data provide estimates of the prevalence of Churg-Strauss syndrome and related conditions in cohorts of asthmatic patients, which may be useful during the pharmacovigilance of new asthma drugs, including the new leukotriene receptor antagonists.

The antineutrophil cytoplasmic antibody-associated vasculitides

Wegener's granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome are small- to medium-vessel vasculitides linked by overlapping pathology and the presence of antineutrophil cytoplasmic antibodies (ANCA). Commonly referred to as the ANCA-associated vasculitides, these diseases are challenging to diagnose and to treat. Distinguishing the ANCA-associated vasculitides from other forms of vasculitis or nonvasculitic processes (such as infection) can be particularly difficult. This review describes the clinical and pathologic hallmarks of the ANCA-associated vasculitides, discusses the role of ANCA assays in diagnosis and treatment, and outlines an approach to the evaluation and management of these diseases.

The Churg Strauss syndrome (allergic granulomatous angiitis): review and update

OBJECTIVES

Review the clinical and physiopathologic aspects of the Churg-Strauss syndrome (CSS), including recent data regarding treatment and possible etiologic and triggering factors.

METHODS

A search of the Medline database was conducted between 1966 and 2002, regarding CSS and related vasculitic conditions. Original articles were reviewed as well as major vasculitis textbooks, which were also examined for original references.

RESULTS

CSS has been increasingly recognized during the past few decades, but remains an uncommon disease of unknown cause. The disorder had been traditionally classified as a variant of polyarteritis nodosa until its updated description by Churg and Strauss in 1951. Although it shares various clinical laboratory and pathologic characteristics with polyarteritis nodosa and Wegener granulomatosis, a distinct combination of features makes it a separate entity. The presence of asthma, usually of adult onset, along with other allergic symptoms, peripheral and tissue eosinophilia, and systemic vasculitis should prompt the clinician to consider the diagnosis, seek potential confirmation with a tissue biopsy, and begin therapy to minimize complications and prevent permanent organ damage. The treatment of CSS has been mainly extrapolated from other vasculitides, and the literature addressing drug therapy for this specific syndrome is limited.

CONCLUSIONS

CSS is a distinct entity that should be recognized and distinguished from other forms of vasculitis to provide the appropriate early treatment, which could prevent permanent organ damage.

Prevalences of polyarteritis nodosa, microscopic polyangiitis, Wegener's granulomatosis, and Churg-Strauss syndrome in a French urban multiethnic population in 2000: a capture-recapture estimate

OBJECTIVE

To estimate the prevalences of polyarteritis nodosa (PAN), microscopic polyangiitis (MPA), Wegener's granulomatosis (WG), and Churg-Strauss syndrome (CSS).

METHODS

Cases were collected in Seine-St. Denis County, a northeastern suburb of Paris, which has 1,093,515 adults (> or =15 years), 28% of whom are of non-European ancestry. The study period encompassed the entire calendar year 2000. Cases were identified by general practitioners, the departments of all the public hospitals and 2 large private clinics, and the National Health Insurance System. The Chapel Hill nomenclature was used to define MPA, and American College of Rheumatology criteria to define WG and CSS; PAN was diagnosed based on clinical laboratory, histological and/or angiographic findings. Three-source capture-recapture analysis was performed to correct for incomplete case ascertainment.

RESULTS

A total of 75 cases were retained and capture-recapture analysis estimated that 23.8 cases had been missed by any 1 of the 3 sources. Accordingly, prevalences per 1,000,000 adults (95% confidence interval [95% CI]) were estimated to be 30.7 (95% CI 21-40) for PAN, 25.1 (95% CI 16-34) for MPA, 23.7 (95% CI 16-31) for WG, and 10.7 (95% CI 5-17) for CSS. The overall prevalence was 2.0 times higher for subjects of European ancestry than for non-Europeans (P = 0.01).

CONCLUSIONS

This study provides the first prevalence estimates for these 4 vasculitides for a multiethnic, urban population. The significantly higher prevalence observed for Europeans may infer a genetic susceptibility of Caucasians. Compared with previous estimates based mostly on rural populations, the higher frequency of PAN and the lower frequency of WG might suggest specific environmental etiologic factors.

Treatment of Churg-Strauss syndrome with high-dose intravenous immunoglobulin

BACKGROUND

In some patients with Churg-Strauss syndrome (CSS), especially those with myocardial or neural involvement, conventional treatment with corticosteroids with or without cyclophosphamide is not effective.

OBJECTIVE

To examine the effects of intravenous high-dose immunoglobulin (IVIG) in patients with CSS who showed poor responsiveness to conventional treatment.

METHODS

We consecutively selected patients with CSS who showed any organ involvement despite corticosteroid treatment with or without cyclophosphamide. The diagnosis was based on the classification criteria of the American College of Rheumatology. IVIG therapy was performed with a dose of 400 mg/kg of immunoglobulin daily for 5 days. Neuropathy was evaluated with the manual muscle strength test and by the skin temperature of affected sites. Cardiac function was examined with ejection fraction by echocardiography and 2 imaging tests of myocardium (iodine 123 metaiodobenzylguanidine and thallium 201).

RESULTS

The manual muscle strength test results were improved, and the skin temperature of both hands and legs was increased by IVIG therapy. In 5 patients with heart failure, the mean +/- SD ejection fraction of the left ventricle increased from 35.2% +/- 13.9% to 61.0% +/- 10.1% (P < .02). The uptake of iodine 123 metaiodobenzylguanidine of the myocardium increased, indicating that the myocardial viability was improved. The thallium 201 images revealed the presence of perfusion defects, which were improved by IVIG therapy.

CONCLUSIONS

Patients with CSS who are resistant to corticosteroid treatment with or without cyclophosphamide may be treated effectively with IVIG therapy.

Churg-Strauss syndrome (CSS) manifested as necrosis of fingers and toes and liver infarction

We report a case of Churg-Strauss syndrome (CSS) with necrosis of the fingers and toes and liver infarction. A 59-year-old man with asthma suddenly noticed that his fingers and toes felt unusually cold. This condition worsened progressively, and some digits became necrotic within several weeks. Laboratory studies revealed hypereosinophilia and an extremely elevated serum level of IgE. Digital subtraction angiography of the extremities revealed extensive irregular narrowing of small and medium-sized arteries in the extremities. Abdominal computed tomography (CT) revealed an area of low density at the periphery of the right lobe of the liver. Angiography revealed irregular narrowing of small arteries that corresponded to the ischemic area. A nerve conduction study suggested sensory nerve neuropathy. The preceding asthma, acute onset of digital necrosis, liver infarction, neuropathy, and hypereosinophilia strongly suggested a diagnosis of CSS. The patient was treated with 40 mg of prednisolone and 120 micro g of intravenous prostaglandin E1 daily, and all the digits that had turned black and necrotic were amputated. After the amputation, the dose of prednisolone was gradually reduced, and no new lesions appeared on the skin or in the liver. The rare possible complications of CSS, including necrosis of digits and liver infarction, should not be ignored.

Investigation of quality of life, mood, pain, disability, and disease status in primary systemic vasculitis

OBJECTIVE

To assess quality of life (QOL) and psychological adjustment in primary systemic vasculitis (PSV), and to assess their relationship to disease-related measures.

METHODS

Fifty-one PSV patients completed questionnaires assessing QOL (Short Form 36 [SF-36]), disability (Health Assessment Questionnaire [HAQ]), and mood (Hospital Anxiety and Depression Scale [HADS]). Illness-related measures, disease activity, and permanent damage scores (the Birmingham Vasculitis Damage Index [BVDI] modified, and the Birmingham Vasculitis Activity Scale modified) were collected. Aspects of the HAQ's psychometric properties were evaluated.

RESULTS

PSV patients' SF-36 scores, except for mental health, were significantly lower than the norms, indicating poorer QOL. Using the HADS, 43.2% of patients reported increased anxiety symptoms and 25.5% increased depressive symptoms. Patients with increased pain when compared with those with little or no pain had significantly impaired scores in all SF-36 subscales, except for mental health; and they scored significantly worse on depression, fatigue, problems with sleep, and symptom severity. Patients with neuropathic symptoms and those taking high levels of steroids had significantly impaired scores on some of the relevant measures. There were no significant correlations between the modified BVDI scores with the SF-36 subscales or with the other self-report disease-related measures. The HAQ showed high internal consistency and high concurrent and discriminant validity.

CONCLUSION

Many aspects of QOL are significantly impaired in PSV. Self-reported pain and disease symptoms, SF-36 scores, and depression and anxiety levels are significant indicators of the adverse impact of vasculitis on patients' lives that need to be assessed and managed.

Recent progress in the pharmacotherapy of Churg-Strauss syndrome

Churg-Strauss syndrome (CSS) is a primary systemic vasculitis occurring primarily in patients with asthma. Unlike other small vessel vasculitides, CSS is characterised by blood and tissue eosinophilia. Corticosteroids are the therapy of first choice for all stages of the disease when active vasculitis needs to be treated rapidly. In patients with severe disease and organ- or life-threatening manifestation, the addition of cyclophosphamide appears to improve the outcome and reduces the incidence of relapses. In cases with an apparently better prognosis and less severe disease, methotrexate can be given as a corticosteroid-sparing agent in order to reduce the cumulative dose of corticosteroids, which is generally high in most cases as long-term administration of corticosteroids is often inevitable in order to control asthma, even if the vasculitis is inactive. In very severe cases of CSS, cyclophosphamide and corticosteroids may be insufficient to induce remission. In these cases, anti-TNF blocking agents such as infliximab or etanercept, may be added for a limited period of time. As this intense immunosuppression increases the risk for infections, a prophylaxis with sulfamethoxazole/trimethoprim is advised. Alternatively, the administration of recombinant IFN-alpha can be a effective when given on a short-term basis in otherwise refractory cases. Whether a continuous administration of immunosuppressive agents in addition to corticosteroids can reduce the frequency of relapses in CSS who are in remission is still unknown. As relapses occur in > 25% of all patients, studies addressing the prevention of relapses in CSS are highly desirable in the future.

Coinvolgimento Ureterale Bilaterale Nella Sindrome di Churg-Strauss: Descrizione di un Nuovo Caso

We report a case of Churg-Strauss syndrome, with bilateral ureteral involvement. We describe the endourological approach to the disease and we also discuss the literature about this argument.