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Penile involvement of immunoglobulin a vasculitis/Henoch-Schönlein purpura. J Pediatr Urol 2021; 17:409.e1-409.e8. [PMID: 33558175 DOI: 10.1016/j.jpurol.2021.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/05/2021] [Accepted: 01/14/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Immunoglobulin A vasculitis/Henoch-Schönlein purpura (IgAV/HSP) is a leukocytoclasia vasculitis of childhood, predominantly affecting the skin, joints, gastrointestinal tract, and kidneys. The involvement of the penis is rare. OBJECTIVE We aimed to describe this rare manifestation of IgAV/HSP and to review the previous studies, including similar cases. METHODS Clinical data were reviewed for two children of penile involvement of IgAV/HSP in our hospital. More clinical cases were retrieved from the databases of PubMed/MEDLINE and Scopus from database inception to February 1, 2020. RESULTS We presented two boys aged three and five years both of whom had penile lesions after presenting with the typical rash of IgAV/HSP on lower extremities. The penile lesions improved entirely in a few days without treatment in one and with corticosteroid treatment in the other. The literature review revealed 12 articles describing 20 patients with penile involvement of IgAV/HSP. The penile findings were edema, erythema, ecchymosis, purpuric rash, edema, color change, stiffness of the shaft or prepuce, and tenderness. Penile lesions appeared before the purpuric rash of IgAV/HSP in three of 22 patients. The penile involvement could make the diagnosis challenging especially if the penile lesions appear before the typical rash of the disease. The lesions improved entirely in the short term in all patients; in five without treatment in fifteen after corticosteroid or immunosuppressive drug treatment. CONCLUSIONS It is important to raise awareness about this rare manifestation among health care providers. It is not clear whether corticosteroid treatment should be initiated for treatment since it seems as a self-limited feature. Treatment with corticosteroids could be considered in the treatment of selected cases especially with systemic involvement.
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102
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IgA Vasculitis and IgA Nephropathy: Same Disease? J Clin Med 2021; 10:jcm10112310. [PMID: 34070665 PMCID: PMC8197792 DOI: 10.3390/jcm10112310] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 12/14/2022] Open
Abstract
Many authors suggested that IgA Vasculitis (IgAV) and IgA Nephropathy (IgAN) would be two clinical manifestations of the same disease; in particular, that IgAV would be the systemic form of the IgAN. A limited number of studies have included sufficient children or adults with IgAN or IgAV (with or without nephropathy) and followed long enough to conclude on differences or similarities in terms of clinical, biological or histological presentation, physiopathology, genetics or prognosis. All therapeutic trials available on IgAN excluded patients with vasculitis. IgAV and IgAN could represent different extremities of a continuous spectrum of the same disease. Due to skin rash, patients with IgAV are diagnosed precociously. Conversely, because of the absence of any clinical signs, a renal biopsy is practiced for patients with an IgAN to confirm nephropathy at any time of the evolution of the disease, which could explain the frequent chronic lesions at diagnosis. Nevertheless, the question that remains unsolved is why do patients with IgAN not have skin lesions and some patients with IgAV not have nephropathy? Larger clinical studies are needed, including both diseases, with a common histological classification, and stratified on age and genetic background to assess renal prognosis and therapeutic strategies.
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Oni L, Gritzfeld JF, Jones C, Sinha MD, Wallace D, Stack M, Kurt-Sukur ED, Quinlan C, Ruggiero B, Raja M, Tullus K. Comment on: European consensus-based recommendations for diagnosis and treatment of immunoglobulin A vasculitis-the SHARE initiative. Rheumatology (Oxford) 2021; 60:e179-e180. [PMID: 32337557 DOI: 10.1093/rheumatology/keaa159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/18/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Louise Oni
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool and Liverpool Health Partners
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool Health Partners, Liverpool
| | - Jenna F Gritzfeld
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool and Liverpool Health Partners
| | - Caroline Jones
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool Health Partners, Liverpool
| | - Manish D Sinha
- Department of Paediatric Nephrology, Evelina London Children's Hospital, London
| | - Dean Wallace
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
| | - Maria Stack
- Department of Paediatric Nephrology, Children's Health Ireland, Dublin, Ireland
| | - Eda Didem Kurt-Sukur
- Department of Paediatric Nephrology, Dr Sami Ulus Children's Hospital, Ankara, Turkey
| | - Catherine Quinlan
- Department of Paediatric Nephrology, The Royal Children's Hospital, Melbourne, Australia
| | - Barbara Ruggiero
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Maduri Raja
- Department of Paediatric Nephrology, Southampton Children's Hospital, Southampton
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street NHS Foundation Trust Hospital, London, UK
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104
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Oni L. Paediatric immune-mediated renal disease: an overview. Nephrol Dial Transplant 2021; 36:596-598. [PMID: 31586428 DOI: 10.1093/ndt/gfz184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/07/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Louise Oni
- Department of Womens and Childrens Health, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
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105
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Characteristics of immune function in the acute phase of Henoch-Schönlein purpura. Clin Rheumatol 2021; 40:3711-3716. [PMID: 33782751 DOI: 10.1007/s10067-021-05707-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Henoch-Schönlein purpura (HSP) is still diagnosed using symptoms and signs together with some histopathological findings. The purpose of this study was to summarize the characteristics and roles of cellular and humoral immunity in children with Henoch-Schönlein purpura (HSP). METHODS A total of 502 cases of patients with acute HSP were diagnosed and observed. The levels of T lymphocyte subsets, natural killer cells (NK cells), and B cells were analyzed by flow cytometry. The serum immunoglobulin G (IgG), immunoglobulin M (IgM), immunoglobulin A (IgA), and complement C3 (C3) and complement C4 (C4) levels were detected by velocity scatter turbidimetry. RESULTS Compared with the healthy groups, the levels of cluster of differentiation 3 (CD3), cluster of differentiation 4 (CD4), B cells, and NK cells and ratio of CD4/CD8 in patients with HSP were decreased (P < 0.05). The levels of IgG, IgA, IgM, and C3 were increased (P < 0.05). Compared with the Kawasaki disease (KD) group, the levels of CD3, CD4, CD8, B cells, NK cells, and IgA in patients with HSP were increased (P < 0.05), and the ratio of CD4/CD8 and levels of IgM, C3, and C4 was decreased (P < 0.05). Compared with the pneumonia group, the levels of CD3, CD4, B cells, and IgA in patients with HSP were increased (P < 0.05), and the ratio of CD4/CD8 and levels of IgM and C4 was decreased (P < 0.05). CONCLUSIONS Cellular immunity and humoral immunity were all involved in the pathogenesis of HSP. The decline of NK cells, B lymphocyte cells, CD3, CD4 the increased secretion of immunoglobulin, and the abnormal appearance of IgA and C3 may exist during the progression. It may indicate a worse prognosis and increasing the risk of dedifferentiation. Cellular immunity was lower, which lead to increased production of inflammatory mediators and increased secretion of immunoglobulin, which then mediated systemic small-vessel vasculitis. Key Points • The pathogenesis of Henoch-Schönlein purpura (HSP) was not completely illuminated. • There was a lack of disease-specific laboratory abnormalities that can be used in the clinical diagnosis of HSP. • We compared the laboratory abnormalities in the immune system of HSP with KD and pneumonia. • Cellular immunity and humoral immunity were all involved in the pathogenesis of HSP. Cellular immunity was lower, which lead to the following pathological changes.
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106
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Song Y, Zhou Q, Qiao J, Chen J. A boy with purpura on the legs. BMJ 2021; 372:n329. [PMID: 33664120 DOI: 10.1136/bmj.n329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Yan Song
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Qin Zhou
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jianjun Qiao
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
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107
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Vaz AS, Penteado R, Cordinhã C, Carmo C, Gomes C. IgA vasculitis (Henoch-Schönlein purpura) nephritis and psoriasis in a child: is there a relationship? J Bras Nefrol 2021; 43:603-607. [PMID: 33605313 PMCID: PMC8940111 DOI: 10.1590/2175-8239-jbn-2020-0101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 11/15/2020] [Indexed: 11/22/2022] Open
Abstract
Background Psoriasis is a chronic immune-mediated disorder that primarily affects the skin in both adults and children but can also have systemic involvement, particularly with arthritis and kidney injury. IgA nephropathy is the most frequent kidney disorder associated with psoriasis. Approximately one third of all cases of psoriasis begin in childhood, but association between psoriasis and renal disorders has scarcely been reported in pediatric patients. Henoch-Schönlein purpura (HSP) is a systemic vasculitis characterized by IgA deposits in the vessel walls of affected organs and in the mesangium of the kidney. HSP nephritis histopathology is identical to IgA nephropathy. Case report A 6-year-old boy with recent onset of psoriasis developed HSP with kidney involvement, clinically manifested by nephrotic-range proteinuria and hematuria. Kidney biopsy revealed fibrocellular glomerular crescents and mesangial IgA deposits compatible with IgA nephropathy. Treatment with systemic corticosteroids led to the control of hematuria, but as nephrotic-range proteinuria persisted, cyclophosphamide was added, leading to a gradual decrease in proteinuria. Conclusions We propose an underlying common mechanism in the pathogenesis of both HSP and psoriasis, involving a dysregulation of the IgA-mediated immune response, which could predispose to both entities as well as to kidney damage and IgA nephropathy in these patients.
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Affiliation(s)
- Ana Sofia Vaz
- Centro Hospitalar e Universitário de Coimbra, Departamento de Pediatria, Serviço de Pediatria Ambulatória, Unidade de Nefrologia Pediátrica, Coimbra, Portugal
| | - Raquel Penteado
- Centro Hospitalar e Universitário de Coimbra, Departamento de Pediatria, Serviço de Pediatria Ambulatória, Unidade de Nefrologia Pediátrica, Coimbra, Portugal
| | - Carolina Cordinhã
- Centro Hospitalar e Universitário de Coimbra, Departamento de Pediatria, Serviço de Pediatria Ambulatória, Unidade de Nefrologia Pediátrica, Coimbra, Portugal
| | - Carmen Carmo
- Centro Hospitalar e Universitário de Coimbra, Departamento de Pediatria, Serviço de Pediatria Ambulatória, Unidade de Nefrologia Pediátrica, Coimbra, Portugal
| | - Clara Gomes
- Centro Hospitalar e Universitário de Coimbra, Departamento de Pediatria, Serviço de Pediatria Ambulatória, Unidade de Nefrologia Pediátrica, Coimbra, Portugal
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108
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Ozen S, Sag E. Childhood vasculitis. Rheumatology (Oxford) 2021; 59:iii95-iii100. [PMID: 32348513 DOI: 10.1093/rheumatology/kez599] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/04/2019] [Indexed: 12/19/2022] Open
Abstract
Vasculitis is a challenging disease for paediatricians. Certain vasculitides are quite common in children whereas others are much rarer compared with adults. The most common vasculitides in childhood are IgA-associated vasculitis (Henoch-Schönlein purpura) and Kawasaki disease, which are usually self-limiting vasculitides although children do develop complications as a result. We now have much better knowledge of how to manage these patients and prevent the deleterious complications. This review provides an up-to-date discussion on childhood vasculitides, including diagnosis, treatment and follow-up strategies, together with a comparison with vasculitides in adults. It also discusses the newly defined monogenic vasculitides that often present during early childhood.
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Affiliation(s)
- Seza Ozen
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Erdal Sag
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University, Ankara, Turkey
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109
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Van de Perre E, Jones RB, Jayne DRW. IgA vasculitis (Henoch-Schönlein purpura): refractory and relapsing disease course in the adult population. Clin Kidney J 2021; 14:1953-1960. [PMID: 34345419 PMCID: PMC8323141 DOI: 10.1093/ckj/sfaa251] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Indexed: 12/26/2022] Open
Abstract
Background The disease course of adult immunoglobulin A (IgA) vasculitis (IgAV; Henoch–Schönlein purpura) has not been well defined. Methods In a retrospective survey, we studied 85 adult IgAV patients with extended follow-up (median 43 months) for 67 patients. Results Only 33 of 67 (49%) achieved complete remission. Ongoing renal disease was the most common persistent organ manifestation, but extra-renal disease activity was also present in >50% of patients not achieving complete remission. Twenty-nine of 67 (43%) had relapsing disease, with 18/67 (27%) experiencing several relapses. Skin disease was the most common feature in relapsing patients, followed by nephritis. At 4 years of follow-up, 6 of 29 (21%) experienced progressive disease and 10/29 (34%) relapsing disease. Five of 67 (7%) developed nephritis after diagnosis, within the first 6 months of follow-up. At final follow-up, 10 of 67 (15%) had chronic kidney disease Stage ≥G3a, 18 (27%) haematuria and 13 (19%) proteinuria. No therapy appeared particularly effective and only 6/17 patients treated with mycophenolate mofetil experienced a good response. Conclusions The disease course of adult IgAV is different from that seen in children, with higher frequency of persisting and relapsing disease. Renal disease is the main determinant of ongoing disease activity, but extra-renal features were seen in >50% of patients with chronic disease activity. No clear conclusions on use or choice of immunosuppressive agent could be made based on our experience.
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Affiliation(s)
- Els Van de Perre
- Department of Nephrology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Rachel B Jones
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis Clinic, Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis Clinic, Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
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110
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Kurt-Şükür ED, Sekar T, Tullus K. Biopsy-proven Henoch-Schönlein purpura nephritis: a single center experience. Pediatr Nephrol 2021; 36:1207-1215. [PMID: 33089378 PMCID: PMC8009786 DOI: 10.1007/s00467-020-04809-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/23/2020] [Accepted: 10/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Knowledge on normal progress and treatment of Henoch-Schönlein purpura nephritis (HSPN) is limited. This study reviews outcome, clinical, pathological, and therapeutic factors affecting the prognosis of HSPN patients. METHODS Forty-nine children with biopsy-confirmed HSPN diagnosed between September 2008 and 2018 were included. Demographics, clinical and laboratory data, treatment, and outcome were recorded at the time of biopsy, 3, 6, 12, and 24 months and at last visit. Clinical outcome was graded according to Meadow's criteria. RESULTS The median age at time of biopsy was 10.1 years (IQR:5.7) and female/male ratio 24/25. At presentation, 40.8% of patients had nonnephrotic proteinuria, 18.4% nephrotic syndrome (NS), 4.1% nephritic syndrome (NephrS), and 36.7% NephrS+NS. There were 11 patients with an estimated glomerular filtration rate below 90 ml/min/1.73 m2. Biopsy specimens were classified according to International Study of Kidney Diseases in Children (ISKDC) and Oxford Classification MEST-C scoring systems. Forty-one patients received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, 37 patients steroids, and 35 patients other immunosuppressive medications. At last visit, 24 patients had stage 1 chronic kidney disease (CKD), three stage 2 CKD, and two had stage 5 CKD. Neither clinical parameters nor ISKDC biopsy grade or treatment modalities effected the final outcome. The Oxford classification showed significantly increased segmental glomerulosclerosis in patients with unfavorable outcome. Favorable outcome was associated with shorter time from kidney involvement to biopsy and start of treatment. CONCLUSION A large proportion of patients continued to show signs of CKD at last follow-up while only a small proportion developed stage 5 CKD.
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Affiliation(s)
- Eda Didem Kurt-Şükür
- Department of Pediatric Nephrology, Dr. Sami Ulus Children’s Hospital, Ankara, Turkey
| | - Thivya Sekar
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kjell Tullus
- Department of Pediatric Pathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
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111
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Gohari A, Matsell DG, Mammen C, Goldman RD. Henoch-Schönlein purpura in children: Use of corticosteroids for prevention and treatment of renal disease. CANADIAN FAMILY PHYSICIAN 2020; 66:895-897. [PMID: 33334956 DOI: 10.46747/cfp.6612895] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
QUESTION A few patients have previously presented to my clinic with palpable purpura, joint inflammation, and severe abdominal pain characteristic of Henoch-Schönlein purpura (HSP). Considering that renal injury is the primary long-term complication of HSP, are corticosteroids effective in preventing or treating renal disease in children with HSP? ANSWER Henoch-Schönlein purpura is self-limiting in 94% of children, but permanent renal injury is reported in one-fifth of children with nephritic or nephrotic features. Corticosteroids have been considered as candidates for preventing and treating renal involvement in HSP. There is a moderate level of evidence to suggest corticosteroids are not effective in preventing renal involvement in HSP. However, based on low-level evidence and similarities with primary immunoglobulin A nephropathy, experts recommend corticosteroids in treating renal involvement in HSP to prevent long-term kidney injury. Dose and duration of therapy should be carefully considered in consultation with a pediatric nephrologist.
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112
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Lawton A, Machta J, Semple T, Gupta A. Pulmonary manifestations of systemic vasculitis in childhood. Breathe (Sheff) 2020; 16:200211. [PMID: 33447293 PMCID: PMC7792777 DOI: 10.1183/20734735.0211-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The systemic vasculitides are a heterogenous group of rare conditions with an incompletely understood aetiology. Any of the systemic vasculitides may cause respiratory disease, but some conditions are more likely to affect the pulmonary system, often through pulmonary infarction and diffuse alveolar haemorrhage. These conditions are often difficult to diagnose due to their rarity and significant clinical overlap with common respiratory conditions. Prompt diagnosis and management can significantly reduce morbidity and mortality. The systemic vasculitides are often difficult to diagnose due to their rarity and significant clinical overlap with common respiratory conditions. Prompt diagnosis and management can reduce associated morbidity and mortality.https://bit.ly/36M5tTB
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Affiliation(s)
- Adam Lawton
- Dept of Paediatrics, Royal London Hospital, London, UK
| | - Joseph Machta
- Royal Free London NHS Foundation Trust, Dept of Paediatrics, London, UK
| | - Thomas Semple
- Royal Brompton Hospital, Dept of Radiology, London, UK
| | - Atul Gupta
- Dept of Paediatric Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK.,Institute for Women's and Children's Health, King's College London, London, UK
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113
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IgA Vasculitis Nephritis: A Case Series and Comparison of Treatment Guidelines. Case Rep Rheumatol 2020; 2020:8863858. [PMID: 33343961 PMCID: PMC7725550 DOI: 10.1155/2020/8863858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 11/14/2020] [Accepted: 11/19/2020] [Indexed: 01/27/2023] Open
Abstract
Immunoglobulin A (IgA) vasculitis nephritis (IgAVN) and IgA nephropathy (IgAN) share many pathological parallels and are viewed as related diseases by many groups. Current treatment guidelines remain vague, controversial, and without consensus, especially regarding the role of immunosuppressive medications. We present five cases of IgAVN encountered at our tertiary care center between 2016 and 2020, which were treated with different immunosuppression regimens. Infection was the leading cause of death in this series. These cases provide evidence that IgAVN should be distinguished from IgAN on a spectrum of IgA-associated glomerulonephritis. The outcomes presented herein suggest that the morbidity and systematic involvement IgAVN is greater than previously believed and that these substantial risks should be reflected in contemporary treatment guidelines.
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114
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Obesity is associated with severe clinical course in children with Henoch-Schonlein purpura. Pediatr Nephrol 2020; 35:2327-2333. [PMID: 32613276 DOI: 10.1007/s00467-020-04672-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/17/2020] [Accepted: 06/11/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND We aimed to evaluate the role of obesity on the clinical course and response to treatment in patients with Henoch-Schonlein purpura (HSP). METHODS Data charts of children with HSP followed in a tertiary hospital between 2000 and 2018 were reviewed retrospectively. Persistent purpura was defined as skin involvement persisting for ≥ 30 days. Mild nephropathy was defined as the presence of microscopical hematuria and/or non-nephrotic proteinuria, while severe nephropathy as nephrotic proteinuria, nephritic syndrome, and/or kidney insufficiency. Obese and non-obese patients were compared for demographic, clinical, and laboratory parameters. RESULTS There were 199 patients (M/F, 104/95; median (IQR) presenting age 7.1 (5.0-9.2) years; follow-up period 17.5 (6-50) months). Obese patients (n = 35 (17.6%)) had significantly higher rate of persistent purpura (46% vs 21%), severe renal involvement (58% vs 31%), high-grade renal histopathological lesions (83% vs 39%), hypertension (29% vs 9%), and increased erythrocyte sedimentation rate (79% vs 56%). Obese patients also showed delayed improvement of cutaneous (25 vs 14 days), articular (12.5 vs 10.0 days), and kidney (280 vs 57 days) symptoms. Obese children used steroids for significantly longer period of time (236 vs 40 days). Furthermore, need for immunosuppressive medications were higher in obese patients (40% vs 9%). CONCLUSIONS Obese children with HSP had higher erythrocyte sedimentation rate, hypertension, and severe renal involvement; showed delayed improvement of skin, joint, and kidney findings; and need more immunosuppressive medications and a longer period of steroid treatment. These findings may be associated with the effect of adipose tissue on inflammation.
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115
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Tan WH, Chai ZT, Guo W, Tang PY, Loh A, Oh CC. Cutaneous IgA vasculitis with crescentic nephropathy presenting with ulcers resembling pyoderma gangrenosum. Australas J Dermatol 2020; 62:e327-e329. [PMID: 33216944 DOI: 10.1111/ajd.13497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/09/2020] [Accepted: 09/27/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Wen Hao Tan
- Department of Dermatology, Singapore General Hospital, Singapore, Singapore
| | - Zi Teng Chai
- Department of Dermatology, Singapore General Hospital, Singapore, Singapore
| | - Weiwen Guo
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Po Yin Tang
- Division of Pathology, Singapore General Hospital, Singapore, Singapore
| | - Alwin Loh
- Division of Pathology, Singapore General Hospital, Singapore, Singapore
| | - Choon Chiat Oh
- Department of Dermatology, Singapore General Hospital, Singapore, Singapore
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116
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Rasmussen C, Tisseyre M, Garon-Czmil J, Atzenhoffer M, Guillevin L, Salem JE, Treluyer JM, Terrier B, Chouchana L. Drug-induced IgA vasculitis in children and adults: Revisiting drug causality using a dual pharmacovigilance-based approach. Autoimmun Rev 2020; 20:102707. [PMID: 33197572 DOI: 10.1016/j.autrev.2020.102707] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/14/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES IgA vasculitis (IgAV) is an immune complex small-vessel vasculitis. Drug-induced IgAV cases were rarely reported in the literature. Drug causality assessment is challenging as many other etiological factors can be involved. We performed a pharmacovigilance study to identify the main drugs reported to induce IgAV. METHODS We used the French pharmacovigilance database (FPVD) and the WHO global individual case safety reports database (VigiBase) to retrieve IgAV cases. Cases from the FPVD were reviewed by two investigators using predefined criteria. Disproportionality analyses (case - non-case approach) were conducted in VigiBase to identify drugs significantly associated with IgAV reporting. RESULTS Of the 467 IgAV cases retrieved from the FPVD, 115 (47 children and 68 adults) have been assessed as definite or probable, reported with 178 suspected drugs. Overall IgAV cases were mainly male (58%), with a median age of 33.5 (8.0-63.3) years. No death was reported. Besides, we identified 1558 possible IgAV cases in VigiBase. Among them, 40 were associated with a disproportionality in IgAV reporting. Drugs were mainly vaccines, antibiotics and TNF-α blockers, these finding being consistent in both databases. IgAV reporting with TNF-α blockers was significantly associated with their use in inflammatory bowel diseases, psoriasis or ankylosing spondylitis compared to other indications. CONCLUSIONS Our systematic study enables the identification of culprit drugs in drug-induced IgAV. These results strengthen the immune pathophysiology of IgAV and the role of underlying disease. The list of suspected drugs may be useful for physicians to manage patients with IgAV and consider appropriate drug discontinuation. KEY MESSAGES What is already known about this subject? IgA vasculitis has multifactorial etiology. To date, possible culprit drugs have been reported only in case reports. What does this study add? Using a dual pharmacovigilance-based approach, we identified drugs associated with the occurrence of IgA vasculitis, such as all types of vaccines, major antibiotics and immunomodulatory agents, mainly TNF-α blockers. How might this impact on clinical practice or future developments? Physicians should be aware of drug-induced IgA vasculitis and we provide evidence on the most frequent implicated drugs.
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Affiliation(s)
- Camille Rasmussen
- National Referral Centre for Systemic and Autoimmune Diseases, Department of Internal Medicine, Cochin Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Mylène Tisseyre
- Regional Center of Pharmacovigilance, Department of Pharmacology, Cochin Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Julie Garon-Czmil
- Department of Clinical Pharmacology and Pharmacovigilance, University Hospital of Nancy Brabois, Vandoeuvre Lès Nancy, France
| | - Marina Atzenhoffer
- Department of Clinical Pharmacology and Pharmacovigilance, Hospices civils de Lyon, 69424 Lyon, France
| | - Loic Guillevin
- National Referral Centre for Systemic and Autoimmune Diseases, Department of Internal Medicine, Cochin Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Joe-Elie Salem
- Department of Pharmacology, Pitié-Salpêtrière Hospital, AP-HP Sorbonne Université, Paris, France
| | - Jean-Marc Treluyer
- Regional Center of Pharmacovigilance, Department of Pharmacology, Cochin Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Benjamin Terrier
- National Referral Centre for Systemic and Autoimmune Diseases, Department of Internal Medicine, Cochin Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Laurent Chouchana
- Regional Center of Pharmacovigilance, Department of Pharmacology, Cochin Hospital, AP-HP Centre - Université de Paris, Paris, France.
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Liao CH, Tsai M, Yang YH, Chiang BL, Wang LC. Onset age is a risk factor for refractory pediatric IgA vasculitis: a retrospective cohort study. Pediatr Rheumatol Online J 2020; 18:86. [PMID: 33172497 PMCID: PMC7654143 DOI: 10.1186/s12969-020-00480-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 11/01/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Though outcome differences between children and adults with immunoglobulin A vasculitis (IgAV) has been well documented, it remains unclear if disease features in pediatric IgAV patients vary with onset age. We aimed to explore clinical features and prognosis of pediatric IgAV stratified by onset age. METHODS We retrospectively reviewed records of patients under 18 years old diagnosed with IgAV from January 1999 to December 2018 in one tertiary medical center in Taiwan. Patients were grouped by onset age: ≤ 6 years old, 6-12 years old (> 6, ≤ 12), and 12-18 years old (> 12, < 18). Demographics, laboratory data, incidence of gastrointestinal, renal, and joint involvement, corticosteroid dependence, recurrence, and refractory disease were analyzed. Recurrence was defined as disease flare-up after complete remission and discontinuation of all medications for at least 3 months. Corticosteroid dependence was defined by more than 6 weeks of daily oral corticosteroid intake. Refractory disease was defined as not achieving complete remission 6 months after disease onset. Statistical analysis was performed using R software (v3.6.0). RESULTS There were 484 IgAV patients, with an onset age of 6.10 (4.72-8.58) (median (IQR)) years old. There were 234 (48.3%) patients ≤6 years old, 210 (43.4%) 6-12 years old, and 40 (8.3%) 12-18 years old. One hundred and thirty (26.9%) patients had renal involvement, which was more frequent in older children (≤ 6 years old, 18.4%; 6-12 years old, 31.0%; 12-18 years old, 55.0%; p < 0.001). There were 361 patients (74.6%) with joint involvement; younger children were affected more frequently (≤ 6 years old, 82.1%; 6-12 years old, 71.9%; 12-18 years old, 45.0%; p < 0.001). Gastrointestinal involvement was present in 311 (64.3%) patients, showing no difference among age groups. There were 46 patients (9.5%) with recurrent IgA vasculitis, 136 (28.1%) with corticosteroid dependent and 76 (15.7%) with refractory disease. Corticosteroid dependence and refractory disease occurred more frequently as onset age increased (p < 0.001). CONCLUSION Pediatric IgAV with different onset ages are associated with distinct clinical manifestations and outcomes. The risk of developing corticosteroid dependence, refractory disease and renal involvement increased with onset age.
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Affiliation(s)
- Chun-Hua Liao
- grid.412094.a0000 0004 0572 7815Department of Pediatrics, National Taiwan University Hospital, No.8, Chung Shan South Road, Taipei, 10002 Taiwan
| | - Melody Tsai
- grid.412094.a0000 0004 0572 7815Department of Pediatrics, National Taiwan University Hospital, No.8, Chung Shan South Road, Taipei, 10002 Taiwan
| | - Yao-Hsu Yang
- grid.412094.a0000 0004 0572 7815Department of Pediatrics, National Taiwan University Hospital, No.8, Chung Shan South Road, Taipei, 10002 Taiwan
| | - Bor-Luen Chiang
- grid.412094.a0000 0004 0572 7815Department of Pediatrics, National Taiwan University Hospital, No.8, Chung Shan South Road, Taipei, 10002 Taiwan ,grid.412094.a0000 0004 0572 7815Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Chieh Wang
- Department of Pediatrics, National Taiwan University Hospital, No.8, Chung Shan South Road, Taipei, 10002, Taiwan.
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118
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Alonso de la Hoz J, Martínez Antequera CE, Fernández Manso B, Llorente Otones L, de Inocencio Arocena J. Hemorrhagic Bullous IgA Vasculitis (Schönlein-Henoch purpura), Does it Have a Worse Prognosis? REUMATOLOGIA CLINICA 2020; 17:S1699-258X(20)30195-9. [PMID: 32893147 DOI: 10.1016/j.reuma.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/17/2020] [Accepted: 07/08/2020] [Indexed: 06/11/2023]
Abstract
Haemorrhagic bullous form of IgA vasculitis (IgAV), or Schönlein-Henoch purpura, is an unusual presentation of the disease in paediatric patients (<2%). Blistering eruptions can sometimes be very striking, leading to hospital admissions and administration of high-dose steroids and even immunosuppressants. Review of the literature, however, does not suggest that this clinical form carries a worse prognosis than the other forms of IgAV. In fact, the prognosis of the disease depends on the organic involvement. We present the case of a 5-year-old girl that is very representative. She developed palpable purpura and four days later the skin lesions evolved into blistering lesions. She did not receive any anti-inflammatory nor immunosuppressive treatment and the lesions spontaneously subsided within 14 days. She did not develop any extracutaneous nor systemic involvement.
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Affiliation(s)
- Julia Alonso de la Hoz
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España.
| | | | | | - Lucía Llorente Otones
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - Jaime de Inocencio Arocena
- Unidad de Reumatología Pediátrica, Hospital Universitario 12 de Octubre, Madrid, España; Departamento de Salud Pública y Materno-Infantil, Universidad Complutense de Madrid, Madrid, España
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119
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Initial manifestations and short term follow-up results of Henoch-Schönlein purpura in children: A report from two centers. North Clin Istanb 2020; 7:341-347. [PMID: 33043258 PMCID: PMC7521099 DOI: 10.14744/nci.2019.40370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 12/31/2019] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE: This retrospective observational study aims to demonstrate initial signs and symptoms of Henoch-Schönlein purpura (HSP), search for risk factors for gastrointestinal and renal involvement and give short term follow-up results. METHODS: The files of newly diagnosed HSP patients from two pediatric rheumatology centers in the southeastern part of the country were retrospectively analyzed in this study. Demographic, clinical features and laboratory results were recorded from the files. RESULTS: The cohort consisted of 323 children (males: 53.6%, females: 46.4%). Median age at the time of diagnosis was 7.5 (1.8–17.3) years and the median duration of follow-up was six (3–22) months. The rash was present in all cases but was not the first symptom in 22.9% of the cases. Arthritis and abdominal pain before the development of rash were the initial symptoms in 11.8% and 11.1% of the cases, respectively. Other manifestations were subcutaneous edema (63.2%), arthralgia (57.6%), arthritis (27.6%), myalgia (17.6%), lethargy (10.2%), orchitis (7.5%) and fever (5.3%). Gastrointestinal involvement was seen in 53.3% and renal involvement in 23.5% of the cases. None of the patients developed renal impairment during the follow-up. Older age at diagnosis, necrotic rash, subcutaneous edema, abdominal pain, lethargy, myalgia, arthralgia and arthritis were significantly higher in patients with renal involvement, but none of the demographic, clinical and laboratory features was an independent risk factor for renal or gastrointestinal involvement. CONCLUSION: Abdominal pain, arthritis may be the first manifestation of HSP. Having constitutional symptoms, such as fever, myalgia and lethargy at the time of diagnosis, may be warning signs of a more aggressive course with gastrointestinal and renal involvement.
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120
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Mastrangelo A, Serafinelli J, Giani M, Montini G. Clinical and Pathophysiological Insights Into Immunological Mediated Glomerular Diseases in Childhood. Front Pediatr 2020; 8:205. [PMID: 32478016 PMCID: PMC7235338 DOI: 10.3389/fped.2020.00205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/03/2020] [Indexed: 11/13/2022] Open
Abstract
The kidney is often the target of immune system dysregulation in the context of primary or systemic disease. In particular, the glomerulus represents the anatomical entity most frequently involved, generally as the expression of inflammatory cell invasion or circulant or in situ immune-complex deposition. Glomerulonephritis is the most common clinical and pathological manifestation of this involvement. There are no universally accepted classifications for glomerulonephritis. However, recent advances in our understanding of the pathophysiological mechanisms suggest the assessment of immunological features, biomarkers, and genetic analysis. At the same time, more accurate and targeted therapies have been developed. Data on pediatric glomerulonephritis are scarce and often derived from adult studies. In this review, we update the current understanding of the etiologic events and genetic factors involved in the pathogenesis of pediatric immunologically mediated primitive forms of glomerulonephritis, together with the clinical spectrum and prognosis. Possible new therapeutic targets are also briefly discussed.
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Affiliation(s)
- Antonio Mastrangelo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Jessica Serafinelli
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Marisa Giani
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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121
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Azer S, File W, Leazer R. Intramuscular Hematoma as a Manifestation of IgA Vasculitis. Pediatrics 2020; 145:peds.2019-1668. [PMID: 32291346 DOI: 10.1542/peds.2019-1668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2019] [Indexed: 11/24/2022] Open
Abstract
We describe an atypical pediatric case of immunoglobulin A vasculitis (IgAV), also referred to as Henoch-Schönlein purpura, in which formation of spontaneous hematoma of the paraspinal muscles developed. Spontaneous or unprovoked hematomas rarely occur in IgAV. These manifestations have not been described specifically in the pediatric literature as coinciding with IgAV. These findings are alarming for nonaccidental trauma, particularly in a patient without underlying blood dyscrasia. Our objective for this report is to highlight the possible association of muscular hematoma formation with IgAV and to help providers consider this association when trauma and hemophilia has been ruled out.
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Affiliation(s)
- Sally Azer
- Eastern Virginia Medical School and Children's Hospital of The King's Daughters, Norfolk, Virginia
| | - Wilson File
- Eastern Virginia Medical School and Children's Hospital of The King's Daughters, Norfolk, Virginia
| | - Rianna Leazer
- Eastern Virginia Medical School and Children's Hospital of The King's Daughters, Norfolk, Virginia
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Hernández-Rodríguez J, Carbonell C, Mirón-Canelo JA, Diez-Ruiz S, Marcos M, Chamorro AJ. Rituximab treatment for IgA vasculitis: A systematic review. Autoimmun Rev 2020; 19:102490. [PMID: 32062030 DOI: 10.1016/j.autrev.2020.102490] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 11/07/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immunoglobulin A vasculitis (IgAV) is a systemic small vessel vasculitis for which treatment of severe cases is usually based on glucocorticoids and other conventional immunosuppressive drugs. The role of rituximab for resistant or refractory cases has been explored in isolated case reports and small series. AIMS To perform a literature review of all pediatric and adult patients with IgAV treated with rituximab (RTX) and to assess disease characteristics, RTX efficacy and safety. METHODS We conducted a systematic literature review according to PRISMA guidelines by selecting articles with information on IgAV and RTX up to October 2019. We extracted data on patient characteristics, disease course, RTX efficacy and tolerance. The resulting database was analyzed with statistical software package SPSS v 22.0. RESULTS Among the initial 161 articles found, 20 studies including 35 well-characterized IgAV patients treated with RTX were finally analyzed. Distribution by sex was similar, and the median age at diagnosis was 26 (range: 2 months to 70 years). Patients included were equally diagnosed at pediatric age and in the adulthood. Almost 90% of patients had renal involvement before RTX treatment and resistant or refractory disease to glucocorticoids or other immunosuppressive agents, mainly with renal impairment, was the reason for RTX administration in 85.7% of patients. RTX was used because of contraindication to these previous agents in 8.6% of patients, and as first line therapy in 5.7% of them. With regard to RTX response, 94.3% of patients presented clinical improvement of any type and 74.3% achieved sustained remission at the end of follow-up. Among the 13 (37.1%) patients who experienced a disease relapse, 11 (31.4%) were treated with a new RTX dose, with good disease control in all cases. In terms of treatment requirements, glucocorticoids and additional immunosuppressants were significantly lower after RTX administration. No deaths were observed and the rate of minor RTX-associated adverse effects was of 8.6%. CONCLUSION RTX seems to be a safe and useful agent in inducing disease remission and reducing previous immunosuppressive treatment in IgAV pediatric and adult patients resistant or refractory to glucocorticoids or other immunosuppressive drugs, and in those patients in whom these agents are contraindicated. Nevertheless, controlled clinical trials in are still warranted to clarify the role of RTX in IgAV.
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Affiliation(s)
- José Hernández-Rodríguez
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Cristina Carbonell
- Conective Tissue Diseases Unit, Department of Internal Medicine, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | - José-A Mirón-Canelo
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Salamanca, Salamanca, Spain; Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Sandra Diez-Ruiz
- Department of Medicine, Faculty of Medicine, University of Salamanca, Salamanca, Spain
| | - Miguel Marcos
- Conective Tissue Diseases Unit, Department of Internal Medicine, Hospital Clínico Universitario de Salamanca, Salamanca, Spain; Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Department of Medicine, Faculty of Medicine, University of Salamanca, Salamanca, Spain
| | - Antonio J Chamorro
- Conective Tissue Diseases Unit, Department of Internal Medicine, Hospital Clínico Universitario de Salamanca, Salamanca, Spain; Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Department of Medicine, Faculty of Medicine, University of Salamanca, Salamanca, Spain.
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123
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Di Pietro GM, Castellazzi ML, Mastrangelo A, Montini G, Marchisio P, Tagliabue C. Henoch-Schönlein Purpura in children: not only kidney but also lung. Pediatr Rheumatol Online J 2019; 17:75. [PMID: 31752918 PMCID: PMC6873759 DOI: 10.1186/s12969-019-0381-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/12/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Henoch-Schönlein Purpura (HSP) is the most common vasculitis of childhood and affects the small blood vessels. Pulmonary involvement is a rare complication of HSP and diffuse alveolar hemorrhage (DAH) is the most frequent clinical presentation. Little is known about the real incidence of lung involvement during HSP in the pediatric age and about its diagnosis, management and outcome. METHODS In order to discuss the main clinical findings and the diagnosis and management of lung involvement in children with HSP, we performed a review of the literature of the last 40 years. RESULTS We identified 23 pediatric cases of HSP with lung involvement. DAH was the most frequent clinical presentation of the disease. Although it can be identified by chest x-ray (CXR), bronchoalveolar lavage (BAL) is the gold standard for diagnosis. Pulse methylprednisolone is the first-line of therapy in children with DAH. An immunosuppressive regimen consisting of cyclophosphamide or azathioprine plus corticosteroids is required when respiratory failure occurs. Four of the twenty-three patients died, while 18 children had a resolution of the pulmonary involvement. CONCLUSIONS DAH is a life-threatening complication of HSP. Prompt diagnosis and adequate treatment are essential in order to achieve the best outcome.
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Affiliation(s)
- Giada Maria Di Pietro
- 0000 0004 1757 2822grid.4708.bFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Pediatric Highly Intensive Care Unit, Università degli Studi di Milano, 20122 Milan, Italy
| | - Massimo Luca Castellazzi
- ASST NORDMILANO, Ospedale di Sesto San Giovanni, Pediatric and Neonatology Unit, Sesto San Giovanni, 20099 Milan, Italy
| | - Antonio Mastrangelo
- 0000 0004 1757 2822grid.4708.bFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, Pediatric Nephrology and Dialysis Unit, Università degli Studi di Milano, 20122 Milan, Italy
| | - Giovanni Montini
- 0000 0004 1757 2822grid.4708.bFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, Pediatric Nephrology and Dialysis Unit, Università degli Studi di Milano, 20122 Milan, Italy
| | - Paola Marchisio
- 0000 0004 1757 2822grid.4708.bFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Pediatric Highly Intensive Care Unit, Università degli Studi di Milano, 20122 Milan, Italy
| | - Claudia Tagliabue
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Pediatric Highly Intensive Care Unit, 20122, Milan, Italy.
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Ekinci RMK, Balci S, Melek E, Karabay Bayazit A, Dogruel D, Altintas DU, Yilmaz M. Clinical manifestations and outcomes of 420 children with Henoch Schönlein Purpura from a single referral center from Turkey: A three-year experience. Mod Rheumatol 2019; 30:1039-1046. [PMID: 31662011 DOI: 10.1080/14397595.2019.1687074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objectives: Henoch Schönlein Purpura (HSP) is the most common systemic vasculitis in childhood. We aimed to evaluate the clinical features, seasonal variation, treatment outcomes and the possible predicting factors related to outcome among a large cohort of pediatric HSP patients.Methods: We conducted a medical record review study between July 2016 and January 2019 and evaluated the clinical manifestations and potential risk factors for severe gastrointestinal (GI) involvement, biopsy-proven nephritis and relapses.Results: The study included 420 HSP patients, of which the mean age at diagnosis was 7.68 ± 3.15 years. Clinical manifestations were arthralgia and/or arthritis (n = 244, 58.1%), abdominal pain (n = 235, 56%), subcutaneous edema (n = 163, 38.8%), and renal involvement (n = 125, 29.8%). Disease recurred for at least once, in 69 (16.4%) patients and colchicine treatment yielded a favorable response in 11 of 12 relapsing patients, who did not respond to ibuprofen or steroids. Frequencies of renal involvement and biopsy-proven nephritis were higher in patients with severe GI involvement. Besides, patients with biopsy-proven nephritis had higher rates of abdominal pain, intussusception, severe GI involvement, and systemic steroid administration.Conclusion: We speculate that renal involvement, biopsy-proven nephritis and severe GI involvement can be related to each other. Colchicine may be effective in patients with relapsing disease.
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Affiliation(s)
| | - Sibel Balci
- Faculty of Medicine, Department of Pediatric Rheumatology, Cukurova University, Adana, Turkey
| | - Engin Melek
- Faculty of Medicine, Department of Pediatric Nephrology, Cukurova University, Adana, Turkey
| | - Aysun Karabay Bayazit
- Faculty of Medicine, Department of Pediatric Nephrology, Cukurova University, Adana, Turkey
| | - Dilek Dogruel
- Faculty of Medicine, Department of Pediatric Allergy and Immunology, Cukurova University, Adana, Turkey
| | - Derya Ufuk Altintas
- Faculty of Medicine, Department of Pediatric Allergy and Immunology, Cukurova University, Adana, Turkey
| | - Mustafa Yilmaz
- Faculty of Medicine, Department of Pediatric Rheumatology, Cukurova University, Adana, Turkey
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Hočevar A, Ostrovršnik J, Tomšič M, Rotar Ž. Comment on: European consensus-based recommendations for diagnosis and treatment of immunoglobulin A vasculitis – the SHARE initiative. Rheumatology (Oxford) 2019; 58:1695-1697. [DOI: 10.1093/rheumatology/kez241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Alojzija Hočevar
- Department of Rheumatology, University Medical Centre Ljubljana and
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jaka Ostrovršnik
- Department of Rheumatology, University Medical Centre Ljubljana and
| | - Matija Tomšič
- Department of Rheumatology, University Medical Centre Ljubljana and
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Žiga Rotar
- Department of Rheumatology, University Medical Centre Ljubljana and
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126
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Nuutinen M. Comment on: European consensus-based recommendations for diagnosis and treatment of immunoglobulin A vasculitis-the SHARE initiative. Rheumatology (Oxford) 2019; 58:1697. [PMID: 31243449 DOI: 10.1093/rheumatology/kez257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 05/24/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Matti Nuutinen
- Department of Children and Adolescents, Oulu University Hospital.,PEDEGO Research Unit, Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology, Medical Research Center Oulu, Oulu, Finland
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Pagnoux C, Mendel A. Treatment of systemic necrotizing vasculitides: recent advances and important clinical considerations. Expert Rev Clin Immunol 2019; 15:939-949. [DOI: 10.1080/1744666x.2019.1656527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, Mount Sinai Hospital, University Health Network, Toronto, Ontario, Canada
- Canadian Vasculitis research network (CanVasc), Canada
| | - Arielle Mendel
- Vasculitis Clinic, Division of Rheumatology, Mount Sinai Hospital, University Health Network, Toronto, Ontario, Canada
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128
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Oni L, Sampath S. Childhood IgA Vasculitis (Henoch Schonlein Purpura)-Advances and Knowledge Gaps. Front Pediatr 2019; 7:257. [PMID: 31316952 PMCID: PMC6610473 DOI: 10.3389/fped.2019.00257] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/06/2019] [Indexed: 12/21/2022] Open
Abstract
Immunoglobulin A vasculitis (IgAV; formerly Henoch Schonlein Purpura) is the most common form of childhood vasculitis. It can occur in any age and peaks around 4-6 years old. It demonstrates seasonal variation implicating a role for environmental triggers and geographical variation. The diagnosis is made clinically and 95% of patients will present with a rash, together with any from a triad of other systems-gastrointestinal, musculoskeletal, and renal. Most cases of IgAV in children have an excellent outcome. Treatment may be required during the acute phase for gastrointestinal involvement and renal involvement, termed IgAV nephritis (previously HSP nephritis), is the most serious long-term manifestation accounting for ~1-2% of all childhood end stage kidney disease (ESKD). It therefore requires a period of renal monitoring conducted for 6-12 months. Patients presenting with nephrotic and/or nephritic syndrome or whom develop significant persistent proteinuria should undergo a renal biopsy to evaluate the extent of renal inflammation and there are now international consensus guidelines that outline the indications for when to do this. At present there is no evidence to support the use of medications at the outset in all patients to prevent subsequent renal inflammation. Consensus management guidelines suggest using oral corticosteroids for milder disease, oral, or intravenous corticosteroids plus azathioprine or mycophenolate mofetil or intravenous cyclophosphamide for moderate disease and intravenous corticosteroids with cyclophosphamide for severe disease. Angiotensin system inhibitors act as adjunctive treatment for persisting proteinuria and frequently relapsing disease may necessitate the use of immunosuppressant agents. Renal outcomes in this disease have remained static over time and progress may be hindered due to many reasons, including the lack of reliable disease biomarkers and an absence of core outcome measures allowing for accurate comparison between studies. This review article summarizes the current evidence supporting the management of this condition highlighting recent findings and areas of unmet need. In order to improve the long term outcomes in this condition international research collaboration is urgently required.
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Affiliation(s)
- Louise Oni
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, United Kingdom.,Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Sunil Sampath
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, United Kingdom
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