Wegener granulomatosis: an analysis of 158 patients

Recurrent Wegener's granulomatosis: a case report and review

BACKGROUND

Wegener's granulomatosis is a granulomatous systemic necrotizing vasculitis with prominent upper airway involvement. Complete remissions can be induced with aggressive management. Despite successful treatment, relapses and recurrences of active disease may occur.

OBJECTIVE

We present a patient who presents with histologically confirmed active disease 17 years following successful therapy.

METHODS

A case report of a 72-year-old man who initially presented at age 50 with necrotizing vasculitis of the upper and lower respiratory tract. Eighteen years following his initial therapy he presented with isolated retroorbital disease. Following re-institution of cytotoxic therapy he appears to be disease-free.

RESULTS

Following re-treatment with cytoxan and prednisone, a second remission was induced. The patient is currently entirely well 1 year off therapy.

CONCLUSION

Wegener's granulomatosis may recur many years following apparent successful and aggressive cytotoxic and anti-inflammatory therapy.

Relapsing Wegener's granulomatosis: successful treatment with cyclosporin-A

We describe the case of a 32-year-old splenectomised man with severe Wegener's granulomatosis which was refractory to conventional treatment with oral cyclophosphamide and prednisolone. Remission was temporarily induced only with plasma exchange or i.v. immunoglobulin. Because of frequent relapses of the disease and cyclophosphamide side effects, he was started on treatment with cyclosporin-A and a long lasting remission was achieved.

Vasculitis: diagnosis and therapy

Vasculitis comprises a broad group of syndromes characterized by inflammation and necrosis in the walls of blood vessels, resulting in narrowing or occlusion of the lumen. The distribution of blood vessel involvement varies considerably and serves as the basis for one classification of the vasculitic syndromes: large vessels (Takayasu arteritis, giant-cell arteritis); medium and small muscular arteries (polyarteritis nodosa, Churg-Strauss syndrome, Wegener's granulomatosis, vasculitis in rheumatic diseases); and small vessels ("hypersensitivity" vasculitis, Henoch-Schonlein purpura, microscopic polyangiitis, cryoglobulinemia). The pathogenesis of most forms of vasculitis is only beginning to be understood, but is probably varied and complex. Because of the variability of vasculitides, there is no single, uniform method of diagnosis and treatment. However, a detailed history, careful physical examination, and appropriate laboratory tests are needed in all cases to determine the type of onset, course of illness, organ systems affected, and extent of involvement. Biopsy examination of involved tissues is nearly always essential for diagnosis, except in Takayasu arteritis, when aortography is usually indicated. In most cases of vasculitis, corticosteroid therapy is necessary. When the organ involvement is broader and more progressive (e.g., in cases of polyarteritis nodosa or Wegener's granulomatosis), a combination of cytotoxic drug and corticosteroids is often needed.

Intravenous immunoglobulin in rheumatic disease

With the advent of numerous commercial preparations of intravenous immunoglobulin preparations since 1981, it is now possible to administer these preparations in significant quantities to cause elevation of serum immunoglobulin levels both in patients with antibody-deficient states and in those with normal circulating immunoglobulin levels. This led to a report of dramatic improvement of thrombocytopenia in a child with agammaglobulinemia following the use of intravenous immunoglobulin preparations for recurrent infections, and further studies in both children and adults with associated symptoms suggested therapeutic efficacy of intravenous immunoglobulin preparations in controlling autoimmune symptoms.

Antineutrophil cytoplasmic antibodies in the classification of vasculitis

Two important types of antineutrophil cytoplasmic antibodies (ANCA) have been identified: anti-proteinase 3 and anti-myeloperoxidase antibodies. In the appropriate clinical setting, the presence of either is virtually diagnostic of the subset of vasculitis that includes Wegener's granulomatosis, microscopic polyangiitis (microscopic polyarteritis), the Churg-Strauss syndrome, idiopathic pauci-immune necrotizing and crescentic glomerulonephritis, and related and overlapping forms of these vasculitidies. The finding of ANCA throughout this group identifies these syndromes as belonging to a single category or spectrum of disease.

Wegener's granulomatosis in the elderly

STUDY OBJECTIVE

To determine if elderly patients with Wegener's granulomatosis (WG) exhibit distinctive clinical features or outcomes compared with patients whose conditions were diagnosed at younger ages.

DESIGN

Retrospective cohort study.

SETTING

University medical center.

PATIENTS

Thirty-three patients with WG diagnosed when 60 years old or older and 34 patients with WG diagnosed at age younger than 60 years, identified by record review of all WG patients seen over an 11-year period.

RESULTS

The prevalence of specific clinical features, progression to end-stage renal disease, mortality rate, and infectious and noninfectious complications of therapy were examined. The prevalence of upper respiratory tract involvement (rhinitis, sinusitis, otitis, epistaxis) and hemoptysis were significantly less common as initial manifestations in the elderly patients, although pulmonary infiltrates were seen more commonly during the course of their disease. Renal insufficiency was more common at the time of diagnosis in the elderly patients (64% vs 35%; p < 0.05). Most notably, CNS involvement was 4.5-fold more common in elderly patients (27% vs 6%; p = 0.02). The overall incidence of infectious and noninfectious complications of therapy was similar between the groups, although the mortality rate was markedly higher in the elderly patients (54% vs 19%; p < 0.01). Almost all deaths were due to overwhelming infection.

CONCLUSIONS

Elderly patients with WG present with distinctive clinical features, particularly a relatively low incidence of upper respiratory tract complaints and a high incidence of CNS involvement. The mortality risk from infectious complications of WG is substantially higher in elderly patients, although this cannot be attributed directly to adverse affects of therapy.

Vasculitis and rapidly progressive glomerulonephritis in the elderly

The proportion of patients with vasculitis and rapidly progressive nephritis aged 70 years or over has risen from about 10% in the 1980s to over 30% in series reported in the 1990s. This study was undertaken to examine the presentation and outcome of such older patients. Seventeen of 56 patients (30%) who presented at two renal units were aged 70 years or over. Mean creatinine level at presentation was 530 mumol/l, and five patients received dialysis at presentation. Outcome was dependent on three factors, namely comorbid pathology, response to immunosuppressive therapy, and the occurrence in three cases of temporary spontaneous partial remission. Overall patient survival at one and two years was 62.5% and 50%, respectively, and 90% and 100% of surviving patients were independent of dialysis at one and two years, respectively. Response to chemotherapy was excellent, with full rehabilitation in many cases and no deaths directly attributable to adverse effects of immunosuppressive therapy. We conclude that diagnosis of vasculitis and rapidly progressive glomerulonephritis by renal biopsy and the subsequent administration of chemotherapy (including cyclophosphamide in many cases) resulted in a worthwhile benefit in these elderly patients.

The epidemiology of Wegener's granulomatosis. Estimates of the five-year period prevalence, annual mortality, and geographic disease distribution from population-based data sources

OBJECTIVE

To estimate the prevalence, annual mortality, and geographic distribution of Wegener's granulomatosis.

METHODS

Analysis of national vital statistics data and hospitalization data from a national survey and from all New York State inpatient facilities.

RESULTS

Between 1979 and 1988, 1,784 death certificates in the United States listed Wegener's granulomatosis as a cause of death. Nationally, an estimated 10,771 hospitalizations included Wegener's granulomatosis among the discharge diagnoses. In New York State, there were 978 hospitalizations among 571 individuals with Wegener's granulomatosis.

CONCLUSION

The prevalence of Wegener's granulomatosis in the United States is approximately 3.0 per 100,000 persons. Clear differences in the geographic distribution of Wegener's granulomatosis are apparent when analysis consider rates of disease in individual counties. Contrary to previous reports, associations between disease exacerbations and season were not apparent.

Prognostic factors in polyarteritis nodosa and Churg-Strauss syndrome. A prospective study in 342 patients

We undertook this study to determine the clinical, biologic, immunologic, and therapeutic factors associated with the prognoses of polyarteritis nodosa (PAN) and Churg-Strauss syndrome (CSS). Three hundred forty-two patients (260 with PAN, 82 with CSS) followed from 1980 to 1993 were included in a prospective study on prognostic factors. Two hundred eighty-eight of these patients were included in the prospective studies on PAN and CSS. Items to be considered for analysis were collected at the time of diagnosis, during the acute phase of the disease. A survival curve was plotted for each clinical and biologic symptom observed in PAN or CSS. Each treatment arm of the prospective therapeutic trials was also tested: 1) prednisone (CS) + oral cyclophosphamide (CYC) + plasma exchanges (PE) versus CS E, 2) CS + PE versus CS, 3) CS + oral CY versus CS + pulse CY, 4) CS + pulse CY + PE versus CS + pulse CY in severe PAN and CSS, and 5) PE + antiviral agents after short-term CS in hepatitis B virus-related PAN. Of the parameters thus evaluated, the following had significant prognostic value and were responsible for higher mortality: proteinuria > 1 g/d (p < 0.0001; relative risk [RR] 3.6), renal insufficiency with serum creatinine > 1.58 mg/DL (p < 0.02; RR 1.86), GI tract involvement (p < 0.008. RR 2.83 for surgery). Cardiomyopathy and CNS involvement were associated with a RR of mortality of 2.18 and 1.76, respectively; these were not statistically significant. Similar survival rates were obtained with the prospectively tested therapies. The five-factors score (FFS) we established considered the prognostic factors creatinemia, proteinuria, cardiomyopathy, GI tract involvement, and CNS signs. Multivariate analysis showed that proteinuria (due to vascular or glomerular disease) and GI tract involvement were independent prognostic factors. When FFS = 0 (none of the 5 prognostic factors present), mortality at 5 years was 11.9%; when FFS = 1 (1 of the 5 factors present), mortality was 25.9% (p < 0.005); when FFS > 2 (3 or more of the 5 factors present), mortality was 45.95% (p < 0.0001 between 0 and 2, p < 0.05 between 1 and 2). We conclude that an initial assessment of PAN or CSS severity enables outcome and mortality to be predicted. The FFS is a good predictor of death and can be used to help the clinician choose the most adequate treatment. Renal and GI signs are the most serious prognostic factors.

Wegener's granulomatosis with gangrene of toes

The cutaneous manifestations of Wegener's granulomatosis (WG) are very variable. Gangrene of digits is extremely rare. We report here one such patient of WG with gangrene of toes.

Antineutrophil cytoplasmic antibodies: major autoantigens, pathophysiology, and disease associations

Antineutrophil cytoplasmic antibodies (ANCA) are important serological markers for the primary systemic vasculitides, including microscopic polyarteritis and necrotizing crescentic glomerulonephritis. Numerous reports have established the clinical utility of ANCA titer in monitoring disease activity, relapses, and response to treatment. ANCA, detected by indirect immunofluorescence (IIF) assays using patient's serum and ethanol-fixed human neutrophils, produce two common fluorescent staining patterns: cytoplasmic (C-ANCA), involving a 29-kD neutral serine protease termed proteinase 3 (PR3), and perinuclear (P-ANCA), the result mainly of myeloperoxidase (MPO), but occasionally by other components of the azurophilic granules including lysozyme, elastase, cathepsins, and lactoferrin. Some sera contain granulocyte-specific antinuclear antibodies (GS-ANA), which require formaldehyde fixation of neutrophils to cross link cytoplasmic antigens for distinguishing between ANCA and the GS-ANA by IIF. Positive IIF is confirmed by Western blot analysis or specific enzyme-linked immunosorbent assay for PR3, MPO, and other neutrophil granule antigens. The C-ANCA pattern is highly specific for Wegener's granulomatosis, a disease characterized by granulomatous inflammation, necrotizing and crescentic glomerulonephritis, and vasculitis; P-ANCA is found in sera of individuals with vasculitis, glomerulonephritis, and several other diseases. ANCA are predominantly immunoglobulin (Ig)G isotype, but may be IgM and IgA. Various pathophysiologic mechanisms have been proposed involving ANCA-mediated neutrophil activation in a hypothetical model of vasculitic diseases: positive signals via the FcgammaRII (CD32) receptor after IgG-ANCA binding to membrane-associated PR3, relevant cytokines, production of adhesion molecules on both activated neutrophils and endothelial cells, and the release of neutrophil reactive oxygen species and degranulation causing endothelial cell damage. Interference of C-ANCA with PR3 proteolysis and PR3 inhibition physiologically by the alpha1-proteinase inhibitor may have a pathogenic role. No convincing data have been reported for the existence of autoreactive T lymphocytes reactive to any degree with the neutrophil azurophilic enzymes. Studies of various drug- and infectious agent-related diseases and ANCA may contribute to understanding the mechanism(s) involved in some vasculitides.

Factors associated with Pneumocystis carinii pneumonia in Wegener's granulomatosis

OBJECTIVE

To determine the factors associated with the occurrence of Pneumocystis carinii pneumonia (PCP) in Wegener's granulomatosis (WG).

METHODS

We retrospectively compared a group of 12 patients with WG and PCP (PCP group), with 32 WG patients without PCP followed over the same period in the same centres (control group).

RESULTS

The mean delay of onset of PCP after the start of the immunosuppressive therapy was 127 (SD 128) days. Before treatment, the clinical and biological features of the two groups were similar, except for the mean lymphocyte count which was lower in the PCP group than in the control group (1060/mm3 v 1426/mm3; p = 0.04). During treatment, both groups were lymphopenic. There was a significant difference between the lowest absolute lymphocyte count in each group (244/mm3 in the PCP group v 738/mm3 in the control group; p = 0.001). During the first three months of treatment, the lymphocyte count was less than 600/mm3 at least once in 10 of the 12 patients in the PCP group and in 11 of the 32 patients in the control group (p < 0.01). The mean cumulative dose of cyclophosphamide was greater in the PCP group than in the control group at the end of both the second (1.55 mg/kg/day v 0.99 mg/kg/day; p = 0.05) and the third (1.67 mg/kg/day v 0.97 mg/kg/day; p = 0.03) months. However, in multivariate analysis, the only two factors independently and significantly associated with the occurrence of PCP were the pretreatment lymphocyte count (p = 0.018) and the lymphocyte count three months after the start of the immunosuppressive treatment (p = 0.014).

CONCLUSIONS

The severity of lymphocytopenia before and during immunosuppressive treatment is the factor best associated with PCP in WG.

Mortality in the rheumatic diseases

OBJECTIVE

To review mortality data in published studies of various rheumatic diseases.

METHODS

A MEDLINE search of the literature on the rheumatic diseases, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, scleroderma, polymyositis, and vasculitis.

RESULTS

Mortality rates higher than expected have been reported in most rheumatic conditions, considerably higher for inflammatory rheumatic diseases. The mortality rates in patients with systemic lupus erythematosus, scleroderma, polymyositis, and vasculitis are often comparable to mortality rates seen in patients with neoplastic or cardiovascular diseases, although the causes of death often are not identified as the rheumatic disease.

CONCLUSION

Mortality has been found to be predicted in most instances by more severe clinical status, and therefore death should not be considered as "unrelated" to the rheumatic disease. These observations may have important implications for clinical care and health policies regarding patients with rheumatic diseases.

Cocaine-associated cerebral vasculitis

Cocaine use is associated with a variety of serious neurological complications, including cerebral infarction, intracerebral and subarachnoid hemorrhage, transient ischemic attacks, migraines, and seizures. We report two cases of intracerebral hemorrhage with biopsy-proven cerebral vasculitis associated with the use of cocaine. The first case involved a 32-year-old man who presented with headache, left-sided hemiparesis, and severe hypertension and who was found to have a large right putaminal hemorrhage on cranial tomographic (CT) scan. Cerebral angiography did not show vasculitic changes, but brain tissue obtained during hematoma evacuation revealed a nonnecrotizing leukocytoclastic angiitis of the small vessels. The second case involved a 20-year-old man who presented with headache, agitation, and speech difficulty that progressed to disorientation and dysphasia. He had a large left temporoparietal hematoma seen on CT scan. Cerebral angiography was consistent with vasculitis, and brain tissue obtained during hematoma evacuation revealed a small vessel vasculitis. In both cases, thorough clinical and laboratory investigations found no evidence of systemic vasculitis or an etiologic agent other than cocaine. We also critically reviewed the previously reported cases of cocaine-associated cerebral vasculitis and the relevant medical literature to discuss the "cocaine-associated vasculitis syndrome" in the context of more established vasculitidies, including hypersensitivity vasculitis. In addition, we outline a diagnostic and therapeutic approach to patients with possible cocaine-associated vasculitis.

Treatment of systemic and renal-limited vasculitic disorders with pooled human intravenous immune globulin

Idiopathic crescentic glomerulonephritis is characterized by an absence of immunohistological evidence of immune deposits, often with evidence of segmental glomerular necrosis. Such pauciimmune crescentic glomerulonephritis is the most common renal manifestation seen in patients with Wegener's granulomatosis, polyarteritis nodosa, and glomerulonephritis associated with other systemic vasculitic disorders (i.e., Churg-Strauss syndrome). Recently, the idiopathic crescentic glomerulonephritides, either in renal-limited form or in association with other systemic vasculitic disorders, were found to have in common a serologic marker, antineutrophil cytoplasmic autoantibodies. These cytoplasmic and perinuclear antineutrophil cytoplasmic autoantibodies are specific for constituents of neutrophil primary granules and monocyte lysosomes. As serologic markers for vasculitic disorders, they are also felt to be directly involved in the pathogenesis of necrotizing vascular injury. In vitro, both perinuclear and cytoplasmic antineutrophil cytoplasmic autoantibodies are capable of causing cytokine-primed neutrophils to undergo degranulation and respiratory burst, releasing toxic oxygen species and lytic enzymes. Anti-idiotype antibodies which inhibit antineutrophil cytoplasmic autoantibodies in vitro, in a V region-dependent manner, are found in pooled human gamma-globulin preparation. Intravenous immune globulin infusions in vivo have produced dramatic improvements in the necrotizing vascular injury produced by antineutrophil cytoplasmic autoantibodies, and a rapid reduction in these autoantibody levels is seen post-intravenous immune globulin infusion in most patients. The proposed mechanisms of action of intravenous immune globulin in vasculitic disorders include Fc-dependent mechanisms, and F(ab')2-dependent mechanisms are likely important. Intravenous immune globulin infusions appear to have an important place in the management of the necrotizing vascular injury. Blinded, randomized, placebo-controlled trials will be necessary to establish definitely intravenous immune globulin as a therapeutic option in vasculitic disorders.

Neuro-ophthalmic manifestations of meningocerebral inflammation from the limited form of Wegener's granulomatosis

PURPOSE

Wegener's granulomatosis is classically a systemic necrotizing granulomatous vasculitis that involves the upper and lower respiratory tracts and kidneys. Ophthalmologic and neurologic manifestations are common. The limited form of Wegener's granulomatosis may have pathologic characteristics consistent with the disease but lacks the complete clinical triad. We studied the clinical, pathologic, laboratory, and radiologic findings of four patients with Wegener's granulomatosis so that others will recognize the disease, even when it occurs in its limited form.

METHODS

From three clinical centers, a chart review disclosed four patients with neuro-ophthalmic findings and the limited form of Wegener's granulomatosis.

RESULTS

Three men and one woman, ranging in age from 40 to 73 years, were studied. All four patients had ocular motor abnormalities (one with oculomotor and trochlear nerve palsies, one with oculomotor nerve palsy, one with trochlear and abducens nerve palsies, and one with horizontal gaze deviation) in addition to other cranial nerve and cerebral abnormalities. Neuroimaging showed prominent meningeal, as well as intraparenchymal, abnormalities. In all patients, results of antineutrophil cytoplasmic antibody tests were initially negative but in one patient were positive at a late stage of the disease. In all patients, results of a biopsy demonstrated necrotizing granulomatous inflammation consistent with Wegener's granulomatosis.

CONCLUSIONS

Neuro-ophthalmic findings may be the earliest manifestations of the limited form of Wegener's granulomatosis. Extensive meningocerebral inflammation can occur before systemic involvement or laboratory confirmation. Early diagnosis by biopsy of affected tissues may facilitate appropriate treatment and prevent progression of the disease.

Subcutaneous nodules in a patient with polyarthritis

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Immunization with anti-neutrophil cytoplasmic antibody (ANCA) induces the production of mouse ANCA and perivascular lymphocyte infiltration

Wegener's granulomatosis (WG) is a granulomatous necrotizing vasculitis associated with the presence of ANCA, predominantly directed against proteinase 3 (PR3). The titres of ANCA correlate with disease activity and titre increases may precede disease exacerbations. Previously, we have shown that it is possible to induce autoimmune disease (systemic lupus erythematosus (SLE) and anti-phospholipid syndrome) in naive mice following active immunization with human autoantibodies, namely anti-DNA and anti-cardiolipin, respectively. The mice developed first anti-autoantibodies and, after about 4 months anti-anti-autoantibodies (Ab3), simulating auto-antibodies (Ab1) in their binding activities, and their presence was associated with the development of disease manifestations, characteristic of the human disease. So far, there is no good animal model for WG. In the current study we have immunized mice with human ANCA with the aim of inducing experimental WG. In two separate studies 30 mice were immunized in their footpads with autoantigen-purified IgG fraction (ANCA) from the sera of two patients with untreated WG, emulsified in Freund's complete adjuvant, followed 3 weeks later by ANCA injection in PBS. In the first experiment mice immunized with ANCA developed sterile microabscesses in the lungs after 8 months, and died after 8-15 months. In the second experiment, mice immunized with ANCA developed after 4 months mouse ANCA, with specificity both to PR3 and to myeloperoxidase, as well as anti-endothelial autoantibodies (AECA), as shown by radioimmunoprecipitation. Pathologically, the immunized mice developed proteinuria but not haematuria, and histological sections of the lungs demonstrated mononuclear perivascular infiltration, while diffuse granular deposition of immunoglobulins was noted in the kidneys. Our results point to a pathogenic role of ANCA in WG, and confirm the importance of the idiotypic network in the etiopathogenesis of autoimmune conditions.

The PiZ gene of alpha 1-antitrypsin as a determinant of outcome in PR3-ANCA-positive vasculitis

We have previously demonstrated that a strong correlation exists between systemic vasculitis with proteinase 3-anti-neutrophil cytoplasm antibodies (PR3-ANCA) and heterozygosity for alpha 1-antitrypsin (alpha 1-AT) deficiency, PiZ. In the present study we characterized the PiZ-positive subgroup by laboratory findings, clinical features and outcome. The series studied consisted of 18 PiZ-positive and 81 PiZ-negative PR3-ANCA patients, comparable in sex ratio, age, C-reactive protein concentrations and renal function at diagnosis, and treatment. PiZ-positive patients had a more disseminated disease as reflected by the number of affected organs (P < 0.01). We found no group differences in relapse tendency. Overall mortality was 39% (7 of 18) in the PiZ-positive and 16% (13 of 81) in the non-PiZ group (P = 0.048). When survival analysis was restricted to 66 patients included in the study at disease onset, the group difference was significant (P = 0.016). The results suggest that the subnormal response of plasma alpha 1-AT seen in PiZ-heterozygotes enhances the risk of dissemination of the vasculitic process and the risk of a fatal outcome. We consider alpha 1-AT phenotyping to be justified in cases of PR3-ANCA-positive vasculitis. Treatments decreasing plasma alpha 1-AT (such as plasmapheresis without plasma replacement) may be deleterious.

Vasculitis

The systemic vasculitides are a group of rare inflammatory conditions resulting in inflammation and necrosis of blood vessel walls. They are somewhat commoner than previously believed with an annual incidence approaching 40 per million. Furthermore the annual incidence of rheumatoid vasculitis is 12.5 per million and Wegener's granulomatosis is 8.5 per million. The first useful classification system for systemic vasculitis was published in 1952, since then a number of different schemes have been published. The major changes have been the recognition of the importance of dominant blood vessel size, the distinction between primary and secondary vasculitis and the incorporation of pathogenetic markers such as ANCA (see Table 6). Until relatively recently there were no widely agreed diagnostic or classification criteria. In 1990 the ACR published criteria for the diagnosis of polyarteritis nodosa, Churg-Strauss syndrome, Wegener's granulomatosis, hypersensitivity vasculitis, Henoch-Schönlein purpura, giant cell arteritis and Takayasu's arteritis. The criteria were provided in both traditional and tree format. Sensitivity and specificity rates varied considerably: 71.0-95.3% for sensitivity and 78.7-99.7% for specificity. The criteria were not tested against the general population or against patients with other connective tissue diseases or rheumatic conditions. In 1993/94 the Chapel Hill Consensus Conference developed and published definitions for the nomenclature of systemic vasculitis based on clinical features. These have not met with universal acceptance. However, they are a useful addition, since their use should result in different centres studying more homogeneous populations of patients and facilitate comparison of data between different centres. Assessment of vasculitis comprises an activity score (BVAS), damage index and quality of life/health status (SF-36). These are recent developments which are still undergoing validation.

Effects of cyclophosphamide on the development of malignancy and on long-term survival of patients with rheumatoid arthritis. A 20-year followup study

OBJECTIVE

To examine the effects of cyclophosphamide (CYC) on the development of malignancies and on the long-term survival of patients with rheumatoid arthritis (RA).

METHODS

We used a longitudinal cohort design in which 119 patients (76 women and 43 men) with refractory RA who were treated with oral CYC between 1968 and 1973 were compared with 119 control patients with RA (matched for age, sex, disease duration, and functional class) who were evaluated during the same time period but did not receive CYC.

RESULTS

There was increased risk of malignancy in the CYC-treated group, with 50 cancers found in 37 patients in the CYC group compared with 26 cancers in 25 of the control patients (P < 0.05). The relative risk of cancer for those treated with CYC was 1.5 (95% confidence interval 0.93-5.5). Nine of the malignancies in the CYC group were bladder cancers and 19 were skin cancers, compared with no bladder cancers and 6 skin cancers in the control group. The total dose of CYC was higher in those who developed cancer, particularly in those with bladder cancer. Three of the bladder cancers occurred 14, 16, and 17 years after CYC had been discontinued.

CONCLUSION

The risk of malignancy, particularly bladder cancer, in RA patients treated with oral CYC continues even 17 years after discontinuation of the drug.

Cutaneous vasculitis and cutaneous vasculopathies

Cutaneous involvement may occur with virtually all syndromes of vasculitis. This can occur primarily as a dermatologic disorder or as a manifestation of a potentially life threatening systemic vasculitis. In this review article, classification, clinical manifestations, pathogenesis and therapy of cutaneous vasculitis will be discussed. Disorders which are primarily vascular in origin but lack a well defined inflammatory phase, referred to as 'vasculopathies' will also be discussed.

Treatment of anti-neutrophil cytoplasmic antibody (ANCA)-associated systemic vasculitis with high-dose intravenous immunoglobulin

In this uncontrolled study 15 patients with ANCA-associated systemic vasculitis, who were poor responders to conventional therapy, were treated with single or multiple courses of intravenous immunoglobulin (IVIG), 30 g/day over 5 days. Clinical and serological evaluation was performed before and 4 weeks after IVIG. Six of the 15 patients experienced clinically significant benefit from IVIG. Improvement was confined to single organ manifestations (skin, ENT findings), no improvement was seen with conjunctivitis and scleritis, pericarditis or nephritis. No patient experienced complete remission after IVIG. Repeated courses of IVIG at 4-week intervals were no more effective than single courses. In six anti-proteinase 3 (PR3)-positive patients pretreatment sera were incubated with F(ab')2 fragments of the IVIG preparation in vitro to measure the inhibitory effect of IVIG on anti-PR3 activity. An inhibition of anti-PR3 activity by 25-70% was observed; this did not correlate with clinical effects. Approximately 40% of patients benefited from IVIG treatment, though complete remission of disease activity did not occur. Neither clinical characteristics nor the inhibitory effect of the IVIG preparation on serum anti-PR3 activity in vitro predicted clinical response to this treatment modality.

Inhibition of proteinase 3 by ANCA and its correlation with disease activity in Wegener's granulomatosis

Detection of circulating antineutrophil cytoplasmic antibodies (ANCA) to the neutrophil serine proteinase, proteinase 3 (PR3), has proven valuable for the diagnosis of Wegener's granulomatosis (WG). However, the importance of these autoantibodies in the pathogenesis of WG remains unknown. It was recently reported that anti-PR3 autoantibodies (PR3-ANCA) from some patients with WG inhibit the proteolytic activity of PR3 and interfere with the inactivation of PR3 by the physiologic inhibitor, alpha 1-proteinase inhibitor (alpha 1-PI). We have studied the effect of PR3-ANCA on the enzymatic activity of PR3 and its correlation with disease activity in patients with WG. We purified IgG from 21 PR3-ANCA positive sera obtained from 17 patients with WG, and determined its effect on the esterolytic and proteolytic activity of purified human PR3 using Boc-Ala-O-Nitrophenyl ester and fluoresceinated-elastin as enzyme substrates. Controls included seven sera containing anti-MPO autoantibodies (MPO-ANCA) from patients with systemic vasculitis and seven ANCA-negative sera obtained from healthy individuals. We found that PR3-ANCA from 9 of the 17 patients significantly inhibited the activity of PR3. There was no correlation between the titers of PR3-ANCA and their inhibitory activity. For one extensively characterized autoantibody, the inhibition reached 70 to 95% at 20-fold molar excess of IgG to enzyme, with an apparent Kiapp of 56.5 microM. This inhibition was non-competitive in nature, and was additive to that produced by alpha 1-PI. A review of the clinical histories of the patients revealed a strong association between active WG and inhibitory autoantibodies.(ABSTRACT TRUNCATED AT 250 WORDS)

Urogenital manifestations of Wegener granulomatosis

We report 8 patients with Wegener granulomatosis (WG) who suffered from symptomatic urogenital involvement including acute urinary retention related to prostatitis, orchitis, ureteral stenosis, bladder pseudotumor, and penile ulceration. Urogenital manifestations occurred as an isolated manifestation of WG in 4 patients, at the onset of the disease in 1 patient, and as the only symptom of relapse in 3. Data used to distinguish specific WG involvement from infection or cyclophosphamide urothelial toxicity are discussed. Four patients needed a surgical procedure consisting of suprapubic cystostomy for acute urinary retention, bilateral ureteral double J stents for bilateral ureteral stenosis, and prostate transurethral resection. Urogenital symptoms promptly resolved with medical therapy. High-dose corticosteroids and immunosuppressive drugs should be used as first-line therapy to avoid unnecessary surgery.

An analysis of forty-two Wegener's granulomatosis patients treated with methotrexate and prednisone

OBJECTIVE

To determine the efficacy of low-dose methotrexate (MTX) plus prednisone in the treatment of Wegener's granulomatosis (WG).

METHODS

An open-label study of weekly low-dose MTX plus prednisone for the treatment of WG was performed. Forty-two patients who did not have immediately life-threatening disease were enrolled into the study. Outcome was determined by clinical characteristics and pathologic, laboratory, and radiographic findings.

RESULTS

Weekly administration of MTX and prednisone resulted in remission of disease in 30 of the 42 patients (71%). The median time to remission was 4.2 months. The estimated median time to relapse for all patients in whom remission was achieved was 29 months. Eight patients who had relapses were treated with a second course of MTX plus prednisone, and a second remission was induced in 6 of the 8 (75%).

CONCLUSION

Weekly low-dose MTX was shown in this study to be an acceptable alternative form of therapy for selected patients with WG who do not have immediately life-threatening disease or who have developed serious cyclophosphamide-associated toxicity.

Neurological manifestation of vasculitis: update on immunopathogenic mechanisms and clinical features

Study of the vasculitides illustrates a spectrum of interactions from physiological to pathological between the immune system and the blood-vessel wall. Endothelial cells demonstrably recruit leukocytes by both antigen-specific and antigen-nonspecific mechanisms in the systemic vasculitides. A cascade of cytokine and factors can initiate, perpetuate, and regulate the close interactions of leukocytes and the endothelium. Specific types of leukocytes (neutrophils, T lymphocytes, eosinophils) predominate in the vascular infiltrates of specific diseases. Other mural cells potentially initiate the inflammatory process; this may be particularly important in the central nervous system where regulatory systems may diminish a primary role of the endothelium in vascular inflammation. Neurological abnormalities are a prominent feature of some vasculitides and rare in others. In polyarteritis nodosa, Wegener's granulomatosis, and lymphomatoid granulomatosis neurological features may be prominent and early. The cutaneous vasculitides, hypersensitivity vasculitis, are seldom associated with neurological abnormalities. Isolated angiitis of the central nervous system is notable because it invariably targets the central nervous system and because it must be distinguished from other causes of central nervous system vasculitis, including infections and toxins. In this article we review some of the recent information adding to our knowledge of the immunopathogenic and clinical features in the vasculitides affecting the nervous system.

Advances in Wegener's granulomatosis

The upper airway is usually the source of initial concern, but lung involvement eventually emerges. Thus, the disease is a reminder that the diagnosis of persistent upper airway problems should have more than a regional focus. Combinations of glucocorticoids and cytotoxic drugs have yielded a dramatic improvement in survival.

Southwestern Internal Medicine Conference: vasculitis--it's time to reclassify

Based on the lack of knowledge of pathophysiologic mechanisms, there has not been a clear and consistent classification of vasculitides. During the past few years, our understanding of these disorders has been enhanced by an appreciation of the role of anti-neutrophil cytoplasmic antibodies. These antibodies exist in two types, a c-ANCA, which corresponds to anti-proteinase 3 antibodies, and a p-ANCA, which corresponds mostly with anti-myeloperoxidase antibodies. Treatment has improved prognosis markedly in these diseases. Most patients can be successfully treated with combinations of treatments including steroids, pulse steroids, cytotoxic agents, and plasmapheresis. Based on antineutrophil cytoplasmic antibodies and response to treatment, a classification is proposed. This classification includes all necrotizing crescentic glomerulonephritis as vasculitis. The vasculitides are divided according to whether they involve large arteries, medium arteries, or small vessels, which include arterioles, capillaries, and venules. Small vessel vasculitides frequently are associated with necrotizing crescentic glomerulonephritis and are divided into three categories: ANCA-associated, anti-GBM associated, and immune complex-associated. Renal biopsy is extremely useful in providing pathologic confirmation of small vessel vasculitis.

Pneumocystis carinii pneumonia in HIV-negative immunocompromised adults

OBJECTIVES

To identify patient populations at risk of Pneumocystis carinii pneumonia (PCP) and assess the potential role of chemoprophylaxis.

METHODS

Review of cases of PCP among patients admitted to a tertiary referral hospital in Sydney between January 1990 and April 1993. Cases were identified by indirect immunofluorescent antibody microscopy performed on respiratory tract specimens.

RESULTS

Ninety-two episodes of PCP were diagnosed in 64 HIV-positive patients and 28 others. All HIV-negative patients had received corticosteroids combined with other immunosuppressive agents before the onset of PCP symptoms, which occurred within six months of immunosuppression. The group included nine of 150 kidney transplant recipients (6%) six of 138 liver transplant recipients (4.3%) and three of 25 patients with Wegener's granulomatosis (12%). Mortality associated with PCP in HIV-negative patients was significantly higher than in those who were HIV-positive (32% v. 8%, P < 0.005).

CONCLUSION

Solid organ transplant recipients and individuals receiving treatment for Wegener's granulomatosis have a significant risk of developing PCP. Given the high mortality associated with this disease in HIV-negative patients, primary PCP chemoprophylaxis should be considered during the first six months of immunosuppression.

Cardiac involvement in Wegener's granulomatosis

Wegener's granulomatosis is a systemic inflammatory disorder of unknown aetiology. The protean clinical presentations depend on the organ(s) involved and the degree of progression from a local to a systemic arteritis. The development of serological tests (antieutrophil cytoplasmic antibodies) allows easier diagnosis of a disease whose incidence is increasing. This is particularly helpful where the presentation is not classic--for example "overlap syndromes"--or where the disease presents early in a more localised form. This is true of cardiac involvement, which is traditionally believed to be rare, but may not be as uncommon as has hitherto been thought (< or = 44%). This involvement may be subclinical or the principal source of symptoms either in the form of localised disease or as part of a systemic illness. Pericarditis, arteritis, myocarditis, valvulitis, and arrhythmias are all recognised. Wegener's granulomatosis should therefore be considered in the differential diagnosis of any non-specific illness with cardiac involvement. This includes culture negative endocarditis, because Wegener's granulomatosis can produce systemic upset with mass lesions and vasculitis. Echocardiography and particularly transoesophageal echocardiography can easily identify and delineate cardiac and proximal aortic involvement and may also be used to assess response to treatment.

Antineutrophil cytoplasmic antibodies and their relevance to the dermatologist

The term vasculitis embraces a heterogeneous group of conditions which may occur as primary phenomena or secondary to disorders such as rheumatoid arthritis or systemic lupus erythematosus. Classification of vasculitis is often difficult in the absence of identifiable aetiological factors or specific serological markers. However, the primary systemic vasculitides can be segregated morphologically, according to the size of blood vessels involved and the presence of granulomata (Table 1). Recently, the discovery of circulating antineutrophil cytoplasmic antibodies (ANCA) in many patients with these disorders, whose differing specificities substantiate the histological classification, has led to interest being focused on their relevance in the development of vasculitis. This paper reviews the historical aspects of the detection of ANCA, and the value of these antibodies in the diagnosis and management of the primary systemic vasculitides likely to be encountered by the dermatologist. The clinical features in patients with these vasculitides are also outlined.