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Higashitani K, Yoshimi R, Sato Y, Watanabe T, Ihata A. Rituximab and Mepolizumab Combination Therapy for Glucocorticoid-Resistant Myocarditis Related to Eosinophilic Granulomatosis With Polyangiitis. Mod Rheumatol Case Rep 2021; 6:87-92. [PMID: 34473835 DOI: 10.1093/mrcr/rxab022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/30/2021] [Indexed: 01/30/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), which belongs to the anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides, is characterized by eosinophil-rich granulomatous inflammation and small to medium-sized vessel vasculitis associated with bronchial asthma and eosinophilia. It sometimes causes severe organ damage, of which myocardial damage is one of the most important for determining the prognosis. A case of EGPA-associated myocarditis that was refractory to glucocorticoid therapy and responded successfully to rituximab (RTX) and mepolizumab (MPZ) combination therapy is presented. A 46-year-old woman was diagnosed with EGPA-associated myocarditis due to pre-existing asthma, eosinophilia, mononeuritis multiplex, and eosinophilic myocarditis by myocardial biopsy. Transthoracic echocardiography showed thickening of the cardiac wall, pericardial effusion, and left ventricular hypokinesis. Although the myocarditis was refractory to methylprednisolone pulse therapy followed by oral high-dose prednisolone, the disease activity reached remission with the successful tapering of glucocorticoid after initiation of the RTX and MPZ combination therapy. Combination therapy with RTX and MPZ can be a good treatment option for EGPA-associated myocarditis for which it is difficult to give intravenous cyclophosphamide due to cardiac dysfunction.
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Affiliation(s)
- Kana Higashitani
- Department of Rheumatology, National Hospital Organization Yokohama Medical Center, Yokohama, Kanagawa, Japan.,Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Yuichiro Sato
- Department of Rheumatology, National Hospital Organization Yokohama Medical Center, Yokohama, Kanagawa, Japan.,Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Toshiyuki Watanabe
- Department of Rheumatology, National Hospital Organization Yokohama Medical Center, Yokohama, Kanagawa, Japan
| | - Atsushi Ihata
- Department of Rheumatology, National Hospital Organization Yokohama Medical Center, Yokohama, Kanagawa, Japan
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152
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Recurrent atelectasis and brain infarction in a patient with anti-neutrophil antibody negative eosinophilic granulomatosis with polyangiitis: a case report. BMC Rheumatol 2021; 5:28. [PMID: 34465397 PMCID: PMC8408937 DOI: 10.1186/s41927-021-00200-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/05/2021] [Indexed: 12/04/2022] Open
Abstract
Background Eosinophilic granulomatosis with polyangiitis (EGPA) is an anti-neutrophil antibody (ANCA)-associated necrotizing vasculitis, which predominantly affects small to medium vessels, and is associated with asthma and eosinophilia. EGPA has two different pathogenic aspects: eosinophilic granulomatous inflammation and ANCA-associated inflammation. A recent histological study of peripheral nerves showed that not only ANCA-associated inflammation but also eosinophil-associated vascular occlusion leads to ischemia. Endobronchial involvement is relatively common especially in the patients with granulomatosis with polyangiitis but rare in patients with EGPA. Central nervous system (CNS) involvement is also rare in patients with EGPA, the pathogenesis and relationship between these two rare conditions have not been elucidated. Case presentation A 62-year-old woman was admitted with numbness, purpura, and eosinophilia. She had a 3-year-history of bronchial asthma. Chest computed tomography showed left lower lobe collapse, and brain magnetic resonance imaging indicated occipital lobe infarction. Skin biopsy findings led to the diagnosis of EGPA. ANCA test results were negative. All symptoms improved after initiating glucocorticoids. However, atelectasis and brain infarction relapsed with increasing eosinophil counts. Atelectasis quickly disappeared with increasing glucocorticoid dose, and glucocorticoid could be reduced to a maintenance dose after the initiation of mepolizumab. Conclusion Both atelectasis and brain infarction might develop not only via ANCA-associated inflammation but also via eosinophilic inflammation.
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153
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Treppo E, Binutti M, Agarinis R, De Vita S, Quartuccio L. Rituximab Induction and Maintenance in ANCA-Associated Vasculitis: State of the Art and Future Perspectives. J Clin Med 2021; 10:jcm10173773. [PMID: 34501224 PMCID: PMC8432126 DOI: 10.3390/jcm10173773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/19/2021] [Accepted: 08/20/2021] [Indexed: 12/15/2022] Open
Abstract
Antineutrophil cytoplasmatic antibody (ANCA)-associated vasculitis (AAV) is a group of rare autoimmune diseases characterized by inflammation of the vascular wall. The pathogenesis of AAV is strongly associated with B cell-derived ANCAs; thus, Rituximab (RTX) has become a promising drug in the induction and maintenance treatment of AAV. The purpose of this review is to describe the efficacy and safety of RTX in the induction of remission and maintenance therapy of AAV. Herein, we summarize the randomized controlled trials that have contributed to the refinement of the use of RTX in AAV in the past decades. RTX has been proven to be effective both in new-onset disease and in relapsing disease. Although the optimal duration of AAV maintenance therapy remains unknown, the ANCAs and the B-cell repopulation may offer support for the administration of further RTX cycles (or not). The safety of RTX is comparable with cyclophosphamide, with the advantage of a low risk of malignancy and no concern for fertility. In conclusion, RTX now plays an important role in the induction and maintenance therapy of AAV. Optimizing RTX-based treatment strategies in AAV is one of the main goals of the current research in AAV.
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Comarmond C, Bensalha S, Lopes A, Dor F, Brocheriou I, Mouly S, Sène D. Comment on: Significance of PR3-ANCA positivity in eosinophilic granulomatosis with polyangiitis (Churg-Strauss). Rheumatology (Oxford) 2021; 60:e297-e299. [PMID: 33682889 DOI: 10.1093/rheumatology/keab213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/20/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- C Comarmond
- Department of Internal Medicine and Clinical Immunology, Lariboisière Hospital, Université de Paris, Paris, France
| | - S Bensalha
- Department of Internal Medicine and Clinical Immunology, Lariboisière Hospital, Université de Paris, Paris, France
| | - A Lopes
- Department of Internal Medicine and Clinical Immunology, Lariboisière Hospital, Université de Paris, Paris, France
| | - F Dor
- Department of Pathology, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - I Brocheriou
- Department of Pathology, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - S Mouly
- Department of Internal Medicine and Clinical Immunology, Lariboisière Hospital, Université de Paris, Paris, France.,INSERM UMR S1144, Université de Paris, Paris, France
| | - D Sène
- Department of Internal Medicine and Clinical Immunology, Lariboisière Hospital, Université de Paris, Paris, France.,INSERM UMR-S976, Université de Paris, Paris, France
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155
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Classification of ANCA-associated vasculitis: differences based on ANCA specificity and clinicopathologic phenotype. Rheumatol Int 2021; 41:1717-1728. [PMID: 34383129 DOI: 10.1007/s00296-021-04966-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/03/2021] [Indexed: 01/24/2023]
Abstract
The classification of vasculitis according to a schema with universal acceptance is challenging, given the heterogeneous and protean nature of these diseases. Formal nomenclature and classification criteria for anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) have suffered several changes since their first description; none provides comprehensive diagnostic and classification criteria. Different factors account for the difficulties in the classification of vasculitis, including the incomplete understanding of the pathogenesis, the multisystemic nature of the disease, the non-specific patterns of vascular involvement, the overlap between entities, and the presence of various classification systems. The present article reviews the classification of AAV considering different points of view, including clinical, serologic, pathogenetic, organ predilection, therapeutic, and prognostic factors, and provides perspectives on future challenges in the understanding of AAV. There is an unmet need for a unifying view of the disease spectrum that considers the constantly evolving paradigms.
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156
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Bettiol A, Urban ML, Dagna L, Cottin V, Franceschini F, Del Giacco S, Schiavon F, Neumann T, Lopalco G, Novikov P, Baldini C, Lombardi C, Berti A, Alberici F, Folci M, Negrini S, Sinico RA, Quartuccio L, Lunardi C, Parronchi P, Moosig F, Espígol-Frigolé G, Schroeder J, Kernder AL, Monti S, Silvagni E, Crimi C, Cinetto F, Fraticelli P, Roccatello D, Vacca A, Mohammad AJ, Hellmich B, Samson M, Bargagli E, Cohen Tervaert JW, Ribi C, Fiori D, Bello F, Fagni F, Moroni L, Ramirez GA, Nasser M, Marvisi C, Toniati P, Firinu D, Padoan R, Egan A, Seeliger B, Iannone F, Salvarani C, Jayne D, Prisco D, Vaglio A, Emmi G. Mepolizumab for Eosinophilic Granulomatosis with Polyangiitis (EGPA): a European multicenter observational study. ARTHRITIS & RHEUMATOLOGY (HOBOKEN, N.J.) 2021; 74:295-306. [PMID: 34347947 PMCID: PMC9305132 DOI: 10.1002/art.41943] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/18/2021] [Accepted: 07/29/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Mepolizumab proved efficacious for eosinophilic granulomatosis with polyangiitis (EGPA, former Churg-Strauss) at the dosage of 300mg/4 weeks in the randomized controlled MIRRA trial. Few successful real-life experiences with the dosage approved for severe eosinophilic asthma (100mg/4 weeks) were recently reported. We retrospectively assessed the effectiveness and safety of mepolizumab 100 and 300mg/4 weeks in a large European EGPA cohort. METHODS We included all EGPA patients treated with mepolizumab at the recruiting centres in 2015-2020. Treatment response was evaluated from month 3 through 24 (T3-T24) after mepolizumab starting. Complete response (CR) was defined as no disease activity (Birmingham Vasculitis Activity Score, BVAS=0) and a prednisone dose ≤4mg/day. Respiratory outcomes included asthma and ear-nose-throat (ENT) exacerbations. RESULTS We included 203 patients, of whom 191 at stable dosage (158 mepolizumab 100mg/4 weeks, 33 300mg/4 weeks). At T3, 25 patients (12.3%) had a CR. CR rates increased to 30.4% and 35.7% at T12 and T24 and were comparable between mepolizumab 100 and 300mg/4 weeks. Mepolizumab led to a significant reduction in BVAS, prednisone dose, eosinophil counts from T3 through T24, with no significant differences between 100 and 300 mg/4weeks. Eighty-two patients (40.4%) experienced asthma exacerbations [57/158 (36%) on 100mg/4 weeks; 17/33 (52%) on 300mg/4 weeks]. Thirty-one (15.3%) experienced ENT exacerbations. Forty-four patients (21.7%) experienced adverse events, most being non-serious (38/44). CONCLUSION Mepolizumab both at 100 and 300mg/4 weeks is effective for EGPA. The two dosages should be compared in the setting of a controlled trial.
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Affiliation(s)
- Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Vincent Cottin
- Department of Respiratory Medicine, Hospices Civils de Lyon, University of Lyon, Lyon, France
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Franco Schiavon
- Unit of Rheumatology, Department of Systems Medicine, Azienda Ospedaliera-Universitaria di Padova, Padova, Italy
| | - Thomas Neumann
- Department of Rheumatology and Immunology, Cantonal Hospital St, Gallen St, Gallen Switzerland.,Department of Internal Medicine III, Jena University Hospital, Jena, Germany
| | - Giuseppe Lopalco
- Rheumatology Unit, Department of Emergency and Organ Transplantation (DETO), Polyclinic Hospital, University of Bari, Bari, Italy
| | - Pavel Novikov
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Carlo Lombardi
- Departmental Unit of Allergology-Clinical Immunology & Pneumology, Fondazione Poliambulanza Istituto Ospedaliero, Brescia
| | - Alvise Berti
- Santa Chiara Hospital, Department of Cellular, Computational and Integrative Biology - CIBIO, University of Trento, Trento, Italy
| | - Federico Alberici
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Marco Folci
- Humanitas Clinical and Research Center-IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Simone Negrini
- Internal Medicine, Clinical Immunology and Translational Medicine Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Centre of Excellence for Biomedical Research and Department of Internal Medicine, University of Genoa, Genoa, Italy
| | | | - Luca Quartuccio
- Department of Medicine, Rheumatology Clinic, University of Udine, ASUFC Udine, Udine, Italy
| | | | - Paola Parronchi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - Georgina Espígol-Frigolé
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Jan Schroeder
- Unit of Allergy and Immunology, ASST GOM Niguarda, Milan, Italy
| | | | - Sara Monti
- Department of Rheumatology, IRCCS Policlinico S. Matteo Fondazione, University of Pavia, Pavia, Italy
| | - Ettore Silvagni
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Claudia Crimi
- Respiratory Medicine Unit, Policlinico-Vittorio Emanuele San Marco" University Hospital, Catania, Italy
| | | | - Paolo Fraticelli
- Department of Internal Medicine, University Hospital "Ospedali Riuniti", Ancona, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit (ERKnet Member)-CMID, Center of Research of Immunopathology and Rare Diseases, San Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Angelo Vacca
- Guido Baccelli Unit of Internal Medicine, Department of Biomedical Sciences and Human Oncology, School of Medicine, Aldo Moro University of Bari, Bari, Italy
| | - Aladdin J Mohammad
- Lund University, Department of Clinical Sciences Lund, Rheumatology, Skåne University Hospital, Lund, Sweden.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitiszentrum Süd, Medius Kliniken, University of Tübingen, Kirchheim unter Teck, Germany
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, Dijon University Hospital, Dijon, France
| | | | - Jan Willem Cohen Tervaert
- Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Maastricht University, Maastricht, Netherlands
| | - Camillo Ribi
- Division of Immunology and Allergy, University Hospital Center of Lausanne, Lausanne, Switzerland
| | - Davide Fiori
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Federica Bello
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Filippo Fagni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Luca Moroni
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Alvise Ramirez
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Mouhamad Nasser
- Department of Respiratory Medicine, Hospices Civils de Lyon, University of Lyon, Lyon, France
| | - Chiara Marvisi
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia.,Università di Modena e Reggio Emilia, Reggio Emilia and Modena, Italy
| | - Paola Toniati
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Davide Firinu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Roberto Padoan
- Unit of Rheumatology, Department of Systems Medicine, Azienda Ospedaliera-Universitaria di Padova, Padova, Italy
| | - Allyson Egan
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - Florenzo Iannone
- Rheumatology Unit, Department of Emergency and Organ Transplantation (DETO), Polyclinic Hospital, University of Bari, Bari, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia.,Università di Modena e Reggio Emilia, Reggio Emilia and Modena, Italy
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Augusto Vaglio
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, Florence, Italy.,Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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157
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Leyens J, Bender TTA, Mücke M, Stieber C, Kravchenko D, Dernbach C, Seidel MF. The combined prevalence of classified rare rheumatic diseases is almost double that of ankylosing spondylitis. Orphanet J Rare Dis 2021; 16:326. [PMID: 34294115 PMCID: PMC8296612 DOI: 10.1186/s13023-021-01945-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rare diseases (RDs) affect less than 5/10,000 people in Europe and fewer than 200,000 individuals in the United States. In rheumatology, RDs are heterogeneous and lack systemic classification. Clinical courses involve a variety of diverse symptoms, and patients may be misdiagnosed and not receive appropriate treatment. The objective of this study was to identify and classify some of the most important RDs in rheumatology. We also attempted to determine their combined prevalence to more precisely define this area of rheumatology and increase awareness of RDs in healthcare systems. We conducted a comprehensive literature search and analyzed each disease for the specified criteria, such as clinical symptoms, treatment regimens, prognoses, and point prevalences. If no epidemiological data were available, we estimated the prevalence as 1/1,000,000. The total point prevalence for all RDs in rheumatology was estimated as the sum of the individually determined prevalences. RESULTS A total of 76 syndromes and diseases were identified, including vasculitis/vasculopathy (n = 15), arthritis/arthropathy (n = 11), autoinflammatory syndromes (n = 11), myositis (n = 9), bone disorders (n = 11), connective tissue diseases (n = 8), overgrowth syndromes (n = 3), and others (n = 8). Out of the 76 diseases, 61 (80%) are classified as chronic, with a remitting-relapsing course in 27 cases (35%) upon adequate treatment. Another 34 (45%) diseases were predominantly progressive and difficult to control. Corticosteroids are a therapeutic option in 49 (64%) syndromes. Mortality is variable and could not be determined precisely. Epidemiological studies and prevalence data were available for 33 syndromes and diseases. For an additional eight diseases, only incidence data were accessible. The summed prevalence of all RDs was 28.8/10,000. CONCLUSIONS RDs in rheumatology are frequently chronic, progressive, and present variable symptoms. Treatment options are often restricted to corticosteroids, presumably because of the scarcity of randomized controlled trials. The estimated combined prevalence is significant and almost double that of ankylosing spondylitis (18/10,000). Thus, healthcare systems should assign RDs similar importance as any other common disease in rheumatology.
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Affiliation(s)
- Judith Leyens
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Department of Neonatology and Pediatric Care, Children's University Hospital, Bonn, Germany
| | - Tim Th A Bender
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Institute of Human Genetics, University Hospital, Bonn, Germany
| | - Martin Mücke
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
| | - Christiane Stieber
- Institute of General Practice and Family Medicine, University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Dmitrij Kravchenko
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Department of Radiology, University Hospital, Bonn, Germany
| | - Christian Dernbach
- Division of Medical Psychology and Department of Psychiatry, University Hospital, Bonn, Germany
| | - Matthias F Seidel
- Department of Rheumatology, Spitalzentrum-Centre hospitalier, Biel-Bienne, Switzerland.
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158
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Mutoh T, Shirai T, Sato H, Fujii H, Ishii T, Harigae H. Multi-targeted therapy for refractory eosinophilic granulomatosis with polyangiitis characterized by intracerebral hemorrhage and cardiomyopathy: a case-based review. Rheumatol Int 2021; 42:2069-2076. [PMID: 34287685 DOI: 10.1007/s00296-021-04950-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/13/2021] [Indexed: 12/15/2022]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic autoimmune disorder classified under anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, predominantly affecting small- to medium-sized vessels, characterized by asthma, eosinophilia, and necrotizing granulomatous inflammation. Most patients with EGPA experience peripheral neuropathy, whereas intracerebral hemorrhage is rare as EGPA-related presentation in central nervous system involvement, causing severe morbidity and mortality. Here, we present a 45-year-old man with refractory EGPA who developed intracerebral hemorrhage as the first manifestation, followed by cardiac involvement. This patient with a history of bronchial asthma developed a right putaminal hemorrhage caused by EGPA. Although intravenous cyclophosphamide (IVCY) and mepolizumab (MPZ) induced remission, relapse was frequently observed. Subsequently, he developed cardiomyopathy despite administration of rituximab (RTX) substituted from IVCY and MPZ. Combined immunosuppressive therapy, including IVCY, MPZ, and RTX was required to inhibit vascular inflammation, leading to sustained remission. We review previously published literature while focusing on the clinical features of patients with intracerebral hemorrhage caused by EGPA and describe clinical characteristics for detecting EGPA in patients with intracerebral hemorrhage, emphasizing rapid evaluation and recognition of EGPA and adequate intervention in the early vasculitic phase of this disease. We also refer to the immunological aspects of this case. It is important to consider "multi-targeted therapy" through interleukin-5 suppression and B cell depletion in the management of refractory EGPA.
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Affiliation(s)
- Tomoyuki Mutoh
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan.
| | - Tsuyoshi Shirai
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hiroko Sato
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hiroshi Fujii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Tomonori Ishii
- Clinical Research, Innovation and Education Center, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hideo Harigae
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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159
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Chung SA, Langford CA, Maz M, Abril A, Gorelik M, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot MA, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Care Res (Hoboken) 2021; 73:1088-1105. [PMID: 34235880 DOI: 10.1002/acr.24634] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/13/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of antineutrophil cytoplasmic antibody-associated vasculitis (AAV), including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). METHODS Clinical questions regarding the treatment and management of AAV were developed in the population, intervention, comparator, and outcome (PICO) format (47 for GPA/MPA, 34 for EGPA). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence and formulate recommendations. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 26 recommendations and 5 ungraded position statements for GPA/MPA, and 15 recommendations and 5 ungraded position statements for EGPA. This guideline provides recommendations for remission induction and maintenance therapy as well as adjunctive treatment strategies in GPA, MPA, and EGPA. These recommendations include the use of rituximab for remission induction and maintenance in severe GPA and MPA and the use of mepolizumab in nonsevere EGPA. All recommendations are conditional due in part to the lack of multiple randomized controlled trials and/or low-quality evidence supporting the recommendations. CONCLUSION This guideline presents the first recommendations endorsed by the American College of Rheumatology and the Vasculitis Foundation for the management of AAV and provides guidance to health care professionals on how to treat these diseases.
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Affiliation(s)
| | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
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160
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Chung SA, Langford CA, Maz M, Abril A, Gorelik M, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot MA, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Rheumatol 2021; 73:1366-1383. [PMID: 34235894 DOI: 10.1002/art.41773] [Citation(s) in RCA: 210] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/13/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of antineutrophil cytoplasmic antibody-associated vasculitis (AAV), including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). METHODS Clinical questions regarding the treatment and management of AAV were developed in the population, intervention, comparator, and outcome (PICO) format (47 for GPA/MPA, 34 for EGPA). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence and formulate recommendations. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 26 recommendations and 5 ungraded position statements for GPA/MPA, and 15 recommendations and 5 ungraded position statements for EGPA. This guideline provides recommendations for remission induction and maintenance therapy as well as adjunctive treatment strategies in GPA, MPA, and EGPA. These recommendations include the use of rituximab for remission induction and maintenance in severe GPA and MPA and the use of mepolizumab in nonsevere EGPA. All recommendations are conditional due in part to the lack of multiple randomized controlled trials and/or low-quality evidence supporting the recommendations. CONCLUSION This guideline presents the first recommendations endorsed by the American College of Rheumatology and the Vasculitis Foundation for the management of AAV and provides guidance to health care professionals on how to treat these diseases.
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Affiliation(s)
| | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
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161
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Menditto VG, Rossetti G, Olivari D, Angeletti A, Rocchi M, Gabrielli A, Pomponio G. Rituximab for eosinophilic granulomatosis with polyangiitis: a systematic review of observational studies. Rheumatology (Oxford) 2021; 60:1640-1650. [PMID: 33471122 DOI: 10.1093/rheumatology/keab046] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 12/13/2020] [Accepted: 12/19/2020] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To analyse the available evidence about the use of rituximab (RTX) and other biologic agents in eosinophilic granulomatosis with polyangiitis (EGPA) patients and to provide useful findings to inform the design of future, reliable clinical trials. METHODS A systematic review was performed. A systematic search was conducted in PubMed/MEDLINE, Scopus, Web of Science and the Cochrane library databases on RTX, and an extensive literature search was conducted on other biologic agents. RESULTS Forty-five papers pertinent to our questions were found: 16 retrospective cohort studies, 8 case series, 3 prospective cohort studies and 18 single case reports, for a total of 368 EGPA patients. More than 80% of evaluable patients achieved complete or partial remission with a tendency towards a higher rate of complete response in the pANCA-positive subgroup. CONCLUSION Although the majority of the evaluable EGPA patients treated with RTX appears to achieve complete remission, we strongly believe that a number of sources of heterogeneity impair a clear interpretation of results and limit their transferability in clinical practice. Differences in design, enrolment criteria, outcome definition and measurement make a comparison among data obtained from studies on RTX and other biologic agents unreliable.
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Affiliation(s)
- Vincenzo G Menditto
- Medicina Interna e Medicina d'Urgenza, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Giulia Rossetti
- Clinica Medica, Università Politecnica delle Marche, Ancona, Italy
| | - Diletta Olivari
- Clinica Medica, Università Politecnica delle Marche, Ancona, Italy
| | | | - Marco Rocchi
- Dipartimento di Scienze Biomolecolari, Università di Urbino, Urbino, Italy
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Menzella F, Galeone C, Ghidoni G, Ruggiero P, Capobelli S, Simonazzi A, Catellani C, Scelfo C, Livrieri F, Facciolongo N. Successful treatment with benralizumab in a patient with eosinophilic granulomatosis with polyangiitis refractory to mepolizumab. Multidiscip Respir Med 2021; 16:779. [PMID: 34221399 PMCID: PMC8239622 DOI: 10.4081/mrm.2021.779] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/15/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Eosinophilic granulomatosis with polyangiitis (EGPA) is characterized by necrotizing eosinophilic granulomatous inflammation that frequently involves the respiratory tract (90% of cases). Asthma in EGPA is systematically severe and often refractory to common treatment, it is corticosteroid resistant and can often anticipate the onset of systemic vasculitis by many years. A release of cytokines necessary for the activation, maturation and survival of eosinophils, such as IL-4, IL-5 and IL-13 occurs in the activated Th-2 phenotype. In particular, IL-5 level is high in active EGPA and its inhibition has become a key therapeutic target. Oral glucocorticoids (OCS) are effective treatment options but unfortunately, frequent relapses occur in many patients and they lead to frequent side effects. As for now, there are currently no official recommendations on doses and treatment schedules in the management of EGPA. Case presentation In this article, we describe the case of a man with EGPA, severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP), with poor asthma and CRSwNP control despite OCS and mepolizumab treatment. Respiratory and vasculitis symptoms improved markedly after therapeutic switch to benralizumab. During the treatment, in addition to clinical effects, we witnessed a depletion of blood eosinophils, as well as an improvement in both pulmonary function tests, CT scan and skin lesions present initially. Conclusions While there are many studies confirming the efficacy of benralizumab in EGPA, the most interesting aspect of our report is that efficacy was confirmed in a patient previously unresponsive to mepolizumab, known to be effective in EGPA.
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Affiliation(s)
- Francesco Menzella
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Carla Galeone
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Giulia Ghidoni
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Patrizia Ruggiero
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Silvia Capobelli
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Anna Simonazzi
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Chiara Catellani
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Chiara Scelfo
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Francesco Livrieri
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Nicola Facciolongo
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
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163
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Jakes RW, Kwon N, Nordstrom B, Goulding R, Fahrbach K, Tarpey J, Van Dyke MK. Burden of illness associated with eosinophilic granulomatosis with polyangiitis: a systematic literature review and meta-analysis. Clin Rheumatol 2021; 40:4829-4836. [PMID: 34159493 PMCID: PMC8599408 DOI: 10.1007/s10067-021-05783-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 11/24/2022]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare disease associated with vascular inflammation and multisystem organ damage. The literature reporting EGPA incidence or prevalence is limited. We performed a systematic literature review and meta-analysis to describe the incidence, prevalence, and disease burden associated with EGPA. Real-world, observational, English-language studies in MEDLINE, MEDLINE In-Process, and Embase up to 6 June, 2019, were included. A single investigator screened all identified titles/abstracts and extracted data; an additional, independent investigator repeated the screening and validated the extracted data. A random-effects meta-analysis was conducted to generate pooled estimates for EGPA incidence and prevalence. Data from 100 eligible publications were extracted (32 with incidence/prevalence data, 65 with morbidity/healthcare resource data; 3 with both types of data). Significant evidence of between-study heterogeneity for reported incidence (p = 0.0013-0.0016) and prevalence (p = 0.0001-0.0006) estimates was observed. Global and European pooled estimates (95% confidence interval) of EGPA incidence were 1.22 (0.93, 1.60) and 1.07 (0.94, 1.35) cases per million person-years, respectively; global and European pooled estimates (95% confidence interval) for EGPA prevalence were 15.27 (11.89, 19.61) and 12.13 (6.98, 21.06) cases per million individuals, respectively. The proportions of patients experiencing relapses, or who had nasal polyps or severe asthma, varied considerably across studies. EGPA healthcare resource use was high, with inpatient admissions and emergency department visits reported for 17-42% and 25-42% of patients, respectively. Our results indicate that although global and European EGPA incidence and prevalence is low, the associated disease burden is substantial. Key points • We performed a systematic literature review and meta-analysis of real-world, observational studies describing the incidence, prevalence, and disease burden associated with eosinophilic granulomatosis with polyangiitis (EGPA). • Based on meta-analysis data from 35 eligible studies reporting incidence and prevalence, the incidence and prevalence of EGPA were low (globally 1.22 cases per million person-years and 15.27 cases per million individuals, respectively). • Among the 49 studies with morbidity and/or healthcare resource data, most reported a large proportion of patients with EGPA relapses and comorbidities of nasal polyps and severe asthma. • Healthcare resource use was also high among patients with EGPA in these studies, with inpatient admissions and emergency department visits reported for 17-42% and 25-42% of patients, respectively. Taken together, these data indicate the substantial disease burden associated with EGPA.
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Affiliation(s)
- Rupert W Jakes
- Epidemiology, GSK, 980 Great West Road, London, TW8 9GS, UK.
| | - Namhee Kwon
- Respiratory Research & Development, GSK, London, UK
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Sartorelli S, Chassagnon G, Cohen P, Dunogué B, Puéchal X, Régent A, Mouthon L, Guillevin L, Terrier B. Revisiting characteristics, treatment and outcome of cardiomyopathy in eosinophilic granulomatosis with polyangiitis (Churg-Strauss). Rheumatology (Oxford) 2021; 61:1175-1184. [PMID: 34156464 DOI: 10.1093/rheumatology/keab514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/11/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Eosinophilic granulomatosis with polyangiitis (EGPA) is a necrotizing eosinophil-rich vasculitis. Specific cardiomyopathy (CM) was described in old studies as the most important predictor of mortality. We aimed to revisit EGPA-related CM and its outcome in recent decades. METHODS We reviewed all EGPA patients managed from 2000 to 2019 in our vasculitis clinic. Baseline characteristics and outcomes were analyzed. EGPA-related CM was defined as clinical or extra-clinical manifestations of patent myocardial involvement, after exclusion of other causes. RESULTS We included 176 patients. Median age was 47 years (IQR 36-58 years). Specific CM was observed in 70 patients (40%). Cardiac symptoms were observed in 81% of CM+ patients, including mainly typical or atypical chest pain and peripheral edema. Abnormal EKG, TTE and cardiac magnetic resonance imaging (CMRI) were found in 72%, 72% and 99% in CM+ patients, respectively, contrasting with abnormalities in 32%, 38% and 60% in CM-negative patients. Late gadolinium enhancement (LGE) was the most frequent abnormality on CMRI (70%). CM+ patients were less frequently ANCA-positive, had less frequent peripheral neuropathy and had higher eosinophil count. Major adverse cardiovascular events (MACE) occurred in 13%, both in CM+ and CM- patients. Abnormal EKG and LGE on CMRI were associated with the occurrence of MACE. Four patients died, but none from cardiac causes. CONCLUSIONS Specific cardiomyopathy is frequent in EGPA, especially in ANCA-negative patients with high eosinophil counts. Long-term outcome was better than previously reported. Abnormal EKG and LGE on CMRI were associated with the occurrence of MACE.
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Affiliation(s)
- Silvia Sartorelli
- Unit of Immunology, Rheumatology, Allergy and Rare disease, IRCCS San Raffaele Hospital, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Guillaume Chassagnon
- Department of Radiology, Cochin Hospital, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Pascal Cohen
- Department of Internal Medicine, Cochin Hospital, Paris, France.,National Referral Centre for Rare Systemic and Autoimmune Diseases of Ile de France, Hôpital Cochin, Paris, France
| | - Bertrand Dunogué
- Department of Internal Medicine, Cochin Hospital, Paris, France.,National Referral Centre for Rare Systemic and Autoimmune Diseases of Ile de France, Hôpital Cochin, Paris, France
| | - Xavier Puéchal
- Department of Internal Medicine, Cochin Hospital, Paris, France.,National Referral Centre for Rare Systemic and Autoimmune Diseases of Ile de France, Hôpital Cochin, Paris, France
| | - Alexis Régent
- Department of Internal Medicine, Cochin Hospital, Paris, France.,National Referral Centre for Rare Systemic and Autoimmune Diseases of Ile de France, Hôpital Cochin, Paris, France
| | - Luc Mouthon
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Department of Internal Medicine, Cochin Hospital, Paris, France.,National Referral Centre for Rare Systemic and Autoimmune Diseases of Ile de France, Hôpital Cochin, Paris, France
| | - Loïc Guillevin
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Department of Internal Medicine, Cochin Hospital, Paris, France.,National Referral Centre for Rare Systemic and Autoimmune Diseases of Ile de France, Hôpital Cochin, Paris, France
| | - Benjamin Terrier
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Department of Internal Medicine, Cochin Hospital, Paris, France.,National Referral Centre for Rare Systemic and Autoimmune Diseases of Ile de France, Hôpital Cochin, Paris, France
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165
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Iudici M, Puéchal X, Pagnoux C, Courvoisier DS, Hamidou M, Blanchard-Delaunay C, Maurier F, Ruivard M, Quemeneur T, Aumaitre O, Guillevin L, Terrier B. Significance of eosinophilia in granulomatosis with polyangiitis: data from the French Vasculitis Study Group Registry. Rheumatology (Oxford) 2021; 61:1211-1216. [PMID: 34142135 DOI: 10.1093/rheumatology/keab495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/03/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To describe disease presentation and long-term outcome of granulomatosis with polyangiitis (GPA) patients according to blood eosinophils count (Eos) at vasculitis diagnosis. METHODS Data from newly diagnosed GPA patients registered in the French Vasculitis Study Group database with available eosinophil count at diagnosis were reviewed. Disease characteristics, rate and type of relapses and overall survival were analyzed according to Eos, categorized as normal (<500/mm3), mild-to-moderate hypereosinophilia (HE) between 500 and 1500/mm3 and severe HE > 1500/mm3. RESULTS Three hundred and fifty-four patients were included. At diagnosis, 90 (25.4%) patients had HE ≥ 500/mm3; they were more likely male (73% vs 56%, p= 0.006) and had more frequent cutaneous manifestations (49% vs 33%, p= 0.01), peripheral neuropathy (32% vs 17%, p= 0.004) and higher BVAS (21 vs 18, p= 0.01), compared with those with Eos <500/mm3. Patients with severe HE (n = 28; median Eos 2355, range 1500-9114) had more frequent renal function worsening at presentation (p= 0.008). After a median follow-up of 3.95 (IQR 1.95-6.76) years, no difference was found in overall relapse rates according to baseline Eos, but those with HE experienced more neurologic (p= 0.013) and skin (p= 0.024) relapses and had more frequently peripheral neuropathy as damage at last follow-up (p= 0.02). Overall survival difference was not significantly different in patients with normal Eos or HE at diagnosis. (p= 0.08). CONCLUSIONS Blood HE at diagnosis, observed in about one quarter of GPA patients, identifies a subgroup of patients with a more severe disease and higher rate of skin and neurological involvement both at presentation and during follow-up.
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Affiliation(s)
- Michele Iudici
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), France, Paris.,Rheumatology Unit, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), France, Paris
| | - Christian Pagnoux
- Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Delphine S Courvoisier
- Rheumatology Unit, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | | | - François Maurier
- Service de médecine interne, Groupe Hospitalier UNEOS, Metz-Vantoux, France
| | - Marc Ruivard
- Service de médecine interne, CHU, Clermont-Ferrand, France
| | - Thomas Quemeneur
- Département de médecine interne, Centre Hospitalier, Valenciennes, France
| | | | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), France, Paris.,Université de Paris, Paris, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), France, Paris.,Université de Paris, Paris, France
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166
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Arsenijević M, Ivančević N, Jovanović D, Radović M, Berisavac I. Rare case of recurrent stroke in a patient with eosinophilic granulomatosis with polyangiitis: a case report. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00328-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Central nervous system involvement is rarely described in eosinophilic granulomatosis with polyangiitis (EGPA) and occurs in 5–9% of patients. Among central nervous system manifestations, cerebral infarctions are the most common. To the best of our knowledge, a recurrent stroke in patients with EGPA without cardiac risk factors during maintenance therapy so far has not been described.
Case presentation
A previously healthy 57-year-old female during the course of 1 year developed asthma, sinusitis, polyneuropathy, muscle weakness, and rash followed by fatigue, myalgia, arthralgia, and fever. After an initial diagnostic evaluation, elevated values of eosinophils, liver enzymes, creatine kinase, lactate dehydrogenase, and inflammatory markers (sedimentation rate and C-reactive protein) were found, and renal impairment was detected. On the third day of hospitalization, she developed left-sided hemiparesis due to an ischemic stroke in the right basal ganglia. She has been diagnosed with EGPA, and oral corticosteroid, immunosuppressive, and antiplatelet therapy were applied. Despite potent treatment and initial recovery, a few weeks later, she developed recurrent ischemic stroke in the left hemisphere and pulmonary embolism as rare and potentially severe complications of EGPA. Assuming that complete disease remission had not been established previously, oral prednisone was initially substituted with intravenous methylprednisolone pulses. During follow-up, immunosuppressive therapy was slowly discontinued, oral corticosteroid therapy was reduced to a maintenance dose, and thromboembolic events were well controlled by oral anticoagulant therapy.
Conclusion
Anticoagulant therapy, in addition to immunosuppressive maintenance therapy, should be considered in any EGPA patient who has had an ischemic stroke even without cardiac risk factors.
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167
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Systemic hypereosinophilic syndromes: when autoimmunity is Th2 mediated. Curr Opin Allergy Clin Immunol 2021; 20:175-180. [PMID: 31985544 DOI: 10.1097/aci.0000000000000614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Clinical conditions associated with hypereosinophilia represent a field of particular interest, taking into account the epidemiological impact of the different primary and secondary forms. In addition to a classical Th1 response, also Th2 cells can be involved in the pathogenesis of autoimmune diseases, among them eosinophilic forms such as eosinophilic granulomatosis with polyangiitis. RECENT FINDINGS In patients with severe asthma, recent evidence highlights the role of pathogenic autoantibodies against autologous eosinophil proteins (e.g. eosinophil peroxidase) suggest the role of autoimmune mechanisms, particularly in patients in which asthma is included in eosinophilic vasculitis with antineutrophilic autoantibody positivity. Is now evident that in addition to Th2 cells, also type 2 innate lymphoid cells and Th1/Th17 cells play a central role in the pathogenesis of hypereosinophilic syndrome. SUMMARY The definition of cellular and molecular mechanisms and the critical role of specific cytokines involved in the pathogenesis of hypereosinophilic syndrome open the way to new therapeutic strategies by using biological agents targeting these specific factors.
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168
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Simon M, Morell-Dubois S, Venturelli G, Launay D. Atteinte digestive diagnostiquée par une vidéocapsule au cours d’une granulomatose éosinophilique avec polyangéite. Rev Med Interne 2021. [DOI: 10.1016/j.revmed.2021.03.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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169
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Doubelt I, Cuthbertson D, Carette S, Chung SA, Forbess LJ, Khalidi NA, Koening CL, Langford C, McAlear CA, Moreland LW, Monach PA, Seo P, Specks U, Spiera RF, Springer JM, Sreih AG, Warrington KJ, Merkel PA, Pagnoux C. Clinical Manifestations and Long-Term Outcomes of Eosinophilic Granulomatosis With Polyangiitis in North America. ACR Open Rheumatol 2021; 3:404-412. [PMID: 34032390 PMCID: PMC8207688 DOI: 10.1002/acr2.11263] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/29/2021] [Indexed: 11/08/2022] Open
Abstract
Objective To describe clinical manifestations and outcomes in patients with eosinophilic granulomatosis with polyangiitis (EGPA) in North America. Methods Analysis of patients aged 18 years or older who fulfilled the 1990 American College of Rheumatology Classification Criteria for EGPA enrolled in the Vasculitis Clinical Research Consortium from 2003 to 2019. Main clinical characteristics, treatments, outcomes, and accumulated damage were studied. Results The cohort included 354 patients; 59% female; age at diagnosis of 50.0 (±14) years; 39% were antineutrophil cytoplasm antibody (ANCA) positive. Time from diagnosis to last follow‐up was 7.0 (±6.2) years; 49.4% had one or more relapse. Patients positive for ANCA more commonly had neurological and kidney involvement when compared with patients negative for ANCA, who had more cardiac and lung manifestations. At last study visit, only 35 (12.6%) patients had been off all therapy for more than 2 years during their follow‐up. The overall mortality rate was 4.0% and did not differ by ANCA status or cyclophosphamide use. Scores on the Vasculitis Damage Index (VDI) for 134 patients with two or more visits and more than 1 year of follow‐up increased from 1.7 (±1.8) at enrollment (3.7 [±5.1] years after diagnosis) to 3.35 (±2.1) at last follow‐up (7.5 [±5.8] years after diagnosis), mainly represented by chronic asthma (67.5%), peripheral neuropathy (49.6%), and chronic sinusitis (31.3%). Longer duration of glucocorticoid use and relapse were associated with higher VDI scores. Conclusion This analysis describes the many clinical manifestations and varied outcomes of EGPA and highlights the ongoing need to attain more sustained, long‐term remission to limit the accrual of disease‐related damage.
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Affiliation(s)
- Irena Doubelt
- Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Simon Carette
- Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Lindsy J Forbess
- Cedars Sinai Medical Center, Los Angeles, California, United States
| | - Nader A Khalidi
- McMaster University and St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | | | | | | | - Larry W Moreland
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Paul A Monach
- Division of Rheumatology, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States
| | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland, United States
| | - Ulrich Specks
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, United States
| | - Robert F Spiera
- Hospital for Special Surgery, New York, New York, United States
| | | | | | - Kenneth J Warrington
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, United States
| | | | - Christian Pagnoux
- Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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170
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Osman K, Kendi AT, Maselli D. Isolated angioedema of the bowel caused by aspirin. Clin J Gastroenterol 2021; 14:1096-1102. [PMID: 33999375 PMCID: PMC8127855 DOI: 10.1007/s12328-021-01430-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/29/2021] [Indexed: 12/12/2022]
Abstract
Angioedema is a self-limited, localized tissue swelling, resulting from fluid extravasation into interstitial spaces. It may occur in isolation or be accompanied by urticaria and/or anaphylaxis. The phenomenon has been linked to multiple medications, including non-steroidal anti-inflammatory drugs (NSAIDs) and angiotensin-converting enzyme inhibitors (ACEIs). NSAID-induced angioedema is observed in < 0.3% of patients taking NSAIDs. While isolated visceral angioedema has been reported from ACEIs, it has not been documented from NSAID use, particularly aspirin usage. Here, we report a case of isolated visceral angioedema attributed to aspirin use.
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Affiliation(s)
- Karim Osman
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55902, USA.
- Department of Internal Medicine, Beth Israel Lahey Clinic, Burlington, MA, 01803, USA.
| | - Ayse Tuba Kendi
- Department of Radiology, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55902, USA
| | - Daniel Maselli
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55902, USA
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171
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Zhao EJ, Cheng CV, Mattman A, Chen LYC. Polyclonal hypergammaglobulinaemia: assessment, clinical interpretation, and management. LANCET HAEMATOLOGY 2021; 8:e365-e375. [PMID: 33894171 DOI: 10.1016/s2352-3026(21)00056-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 12/13/2022]
Abstract
This Review outlines a practical approach to assessing and managing polyclonal hypergammaglobulinaemia in adults. Polyclonal hypergammaglobulinaemia is most commonly caused by liver disease, immune dysregulation, or inflammation, but can also provide an important diagnostic clue of rare diseases such as histiocyte disorders, autoimmune lymphoproliferative syndrome, Castleman disease, and IgG4-related disease. Causes of polyclonal hypergammaglobulinaemia can be divided into eight categories: liver disease, autoimmune disease and vasculitis, infection and inflammation, non-haematological malignancy, haematological disorders, IgG4-related disease, immunodeficiency syndromes, and iatrogenic (from immunoglobulin therapy). Measuring serum concentrations of C-reactive protein and IgG subclasses are helpful in diagnosis. IL-6-mediated inflammation, associated with persistently elevated C-reactive protein concentrations (≥30 mg/L), is an important driver of polyclonal hypergammaglobulinaemia in some cases. Although the presence of markedly elevated serum IgG4 concentrations (>5 g/L) is around 90% specific for diagnosing IgG4-related disease, mildly elevated serum IgG4 concentrations are seen in many conditions. In most cases, managing polyclonal hypergammaglobulinaemia simply involves treating the underlying condition. Rarely, however, polyclonal hypergammaglobulinaemia can lead to hyperviscosity, requiring plasmapheresis.
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Affiliation(s)
- Eric J Zhao
- Division of Hematology, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | - Catherine V Cheng
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | - Andre Mattman
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Vancouver General Hospital, Vancouver, BC, Canada; Department of Pathology and Laboratory Medicine, St Paul's Hospital, Vancouver, BC, Canada
| | - Luke Y C Chen
- Division of Hematology, University of British Columbia, Vancouver, BC, Canada; Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Vancouver General Hospital, Vancouver, BC, Canada.
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172
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Lim AKH, Antony A, Gingold M, Simpson I, Looi WF, MacDonald MI. Emergence of extrathoracic manifestations of eosinophilic granulomatosis with polyangiitis during benralizumab treatment. Rheumatol Adv Pract 2021; 5:rkab033. [PMID: 34124538 PMCID: PMC8190011 DOI: 10.1093/rap/rkab033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/24/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Andy K H Lim
- General Medicine, Monash Health.,Department of Medicine, School of Clinical Sciences, Monash University
| | - Anna Antony
- Department of Medicine, School of Clinical Sciences, Monash University.,Rheumatology
| | - Michael Gingold
- Department of Medicine, School of Clinical Sciences, Monash University.,Rheumatology
| | | | | | - Martin I MacDonald
- Respiratory and Sleep Medicine, Monash Health, Clayton, Victoria, Australia
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173
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Update on Maintenance Therapies for ANCA-Associated Vasculitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021. [DOI: 10.1007/s40674-021-00176-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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174
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Bello F, Maritati F, Radice A, Sinico RA, Emmi G, Vaglio A. Microarray evaluation of allergen-specific IgE in eosinophilic granulomatosis with polyangiitis. Ann Rheum Dis 2021; 80:1247-1248. [PMID: 33883159 DOI: 10.1136/annrheumdis-2021-220111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Federica Bello
- Biomedical Experimental and Clinical Sciences, University of Florence, Firenze, Italy
| | | | | | - Renato Alberto Sinico
- Medicine and Surgery, Universita degli Studi di Milano-Bicocca Scuola di Medicina e Chirurgia, Monza, Italy.,Clinical Nephrology, Azienda Socio Sanitaria Territoriale di Monza, Monza, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Augusto Vaglio
- Biomedical Experimental and Clinical Sciences, University of Florence, Firenze, Italy
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175
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Oelzner P, Wolf G. Risikostratifizierung bei ANCA-assoziierten
Vaskulitiden. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1380-2984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungANCA-assoziierte Vaskulitiden (AAV) sind nekrotisierende Vaskulitiden der
kleinen bis mittelgroßen Gefäße, welche die
Granulomatose mit Polyangiitis (GPA), die mikroskopische Polyangiitis (MPA)
und die Eosinophile Granulomatose mit Polyangiitis (EGPA) umfassen. AAV
gehen häufig mit Organfunktion-bedrohenden Manifestationen und einer
entsprechend erhöhten Mortalität einher. Für die
Planung von Diagnostik, Therapie und Langzeitbetreuung ist daher eine
Risikostratifizierung im Hinblick auf Mortalität, Entwicklung
schwerer Organinsuffizienzen, insbesondere einer terminalen
Niereninsuffizienz, mögliche Therapieresistenz, Rezidive,
Infektionen und Malignome erforderlich. Wichtige Risikofaktoren für
erhöhte Mortalität und/oder terminale
Niereninsuffizienz sind neben der renalen Beteiligung per se eine bereits
zum Zeitpunkt der Diagnose deutlich eingeschränkte renale Funktion
einschliesslich initialer Dialysepflichtigkeit, eine hohe initiale
Aktivität der AAV gemessen am Birmingham Vaskulitis Activity Score,
aber auch kardiale und gastrointestinale Manifestationen, Infektionen,
Anämie sowie ein Alter von>65 Jahren. Histologisch ist der
Nachweis chronischer irreversibler glomerulärer und
tubulärer Läsionen in der Nierenbiopsie mit einer schlechten
Prognose im Hinblick auf die Nierenfunktion assoziiert. Basierend auf der
histopathologischen Klassifikation der ANCA-assoziierten Glomerulonephritis
(GN) ist der Befund einer sklerosierenden GN mit einer besonders
ungünstigen Prognose assoziiert, während die fokale GN sehr
selten zur terminalen Niereninsuffizienz führt. MPO-ANCA zeigen eine
Assoziation mit chronischen Läsionen in der Nierenbiopsie sowie
erhöhter Mortalität und erhöhtem Risiko für
terminale Niereninsuffizienz. Im Hinblick auf die pulmonale Beteiligung sind
alveoläre Hämorrhagie und interstitielle Lungenerkrankung
mit einer erhöhten Mortalität assoziiert. Bei EGPA wird die
Prognose entscheidend durch die Kardiomyopathie bestimmt. Risikofaktoren
für Rezidive weichen erheblich von denen für
Mortalität und terminale Niereninsuffizienz ab. Ein erhöhtes
Rezidivrisiko besteht bei Nachweis von PR3-ANCA, GPA und pulmonaler
Beteiligung. Auch bei granulomatösen Läsionen, Beteiligung
des oberen Respirationstraktes und kardiovaskulären Manifestationen
wird ein erhöhtes Rezidivrisiko beschrieben. Im Gegensatz zur
Assoziation einer initial schlechten Nierenfunktion mit Mortalität
und terminaler Niereninsuffizienz, wurde für Patienten mit initial
guter Nierenfunktion ein erhöhtes Rezidivrisiko gezeigt. Weitere
Risikofaktoren für Rezidive sind Staphylokokken-Besiedelung der
Nase, frühere Rezidive und ANCA-Positivität nach
Remissionsinduktion. Titeranstieg oder Wiederauftreten von ANCA zeigen nur
eine moderate Beziehung zum Rezidivrisiko. Der prädiktive Wert
für Rezidive ist offenbar bei bestimmten Subgruppen, wie bei
Patienten mit renaler Beteiligung und pulmonaler Hämorrhagie sowie
bei mit Rituximab-behandelten Patienten besser als bei Patienten mit
granulomatösen Manifestationen. Daher ist eine Therapieentscheidung
allein auf Basis der Entwicklung der ANCA-Titer nicht möglich.
Risikofaktoren für schwere Infektionen sind höher dosierte
und prolongierte Glukokortikoidtherapie, Leuko- und Lymphopenie,
höheres Lebenalter, Niereninsuffizienz und pulmonale Beteiligung.
Die Malignomrate insbesondere für Nicht-Melanom-Hauttumoren,
Harnblasenkarzinome und Leukämie ist bei AAV erhöht und
zeigt eine Assoziation mit hohen kumulativen Cyclophosphamiddosen. Da
insbesondere frühzeitige irreversible Organschäden die
Prognose bestimmen und Rezidive die Entwicklung irreversibler
Schäden treiben, sind frühestmögliche Diagnose und
Therapie sowie rasches Erkennen und Vermeiden von Rezidiven essentiell
für die Risikominimierung.
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Affiliation(s)
- Peter Oelzner
- Rheumatologie/Osteologie, Klinik für Innere Medizin
III, Universitätsklinikum Jena, Jena, Deutschland
| | - Gunter Wolf
- Nephrologie, Klinik für Innere Medizin III,
Universitätsklinikum Jena, Jena, Deutschland
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176
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Méndez Eirín E, Suárez Ouréns Y, Guerra Vázquez JL. Cardiac manifestations of rheumatic diseases. Med Clin (Barc) 2021; 156:615-621. [PMID: 33836859 DOI: 10.1016/j.medcli.2021.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 11/19/2022]
Abstract
Autoimmune rheumatic diseases are inflammatory disorders that can involve multiple organs, including the heart. The high risk of cardiovascular pathology in these patients is not only due to traditional cardiovascular risk factors, but also to chronic inflammation and autoimmunity. All cardiac structures may be affected during the course of systemic autoimmune diseases (valves, the conduction system, the myocardium, endocardium and pericardium, and coronary arteries), and the cardiac complications have a variety of clinical manifestations. As these are all associated with an unfavourable prognosis, it is essential to detect subclinical cardiac involvement in asymptomatic systemic autoimmune disease patients and begin adequate management and treatment early. In this review, we examine the multiple cardiovascular manifestations in patients with rheumatological disorders and available management strategies.
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Affiliation(s)
- Elizabet Méndez Eirín
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, España.
| | - Yago Suárez Ouréns
- Servicio de Traumatología, Complejo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, España
| | - José Luis Guerra Vázquez
- Servicio de Reumatología, Complejo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, España
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177
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Gokhale M, Bell CF, Doyle S, Fairburn-Beech J, Steinfeld J, Van Dyke MK. Prevalence of Eosinophilic Granulomatosis With Polyangiitis and Associated Health Care Utilization Among Patients With Concomitant Asthma in US Commercial Claims Database. J Clin Rheumatol 2021; 27:107-113. [PMID: 31693654 PMCID: PMC7996234 DOI: 10.1097/rhu.0000000000001198] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate the prevalence and associated disease burden of eosinophilic granulomatosis with polyangiitis (EGPA) in patients with asthma from a US claims database. METHODS Two cohorts were defined using enrollees (aged ≥18 years) from the Optum deidentified Clinformatics Datamart claims database 2010-2014, based on validated EGPA case definitions with varying specificity: EGPA 1 (main cohort; more specific; patients with 2 codes [in any combination] within 12 months of each other for eosinophilia, vasculitis, or mononeuritis multiplex) and EGPA 2 (sensitivity analysis cohort; less specific; patients with 2 codes of above conditions and/or neurologic symptoms within 12 months of each other). Patients had 3 or more asthma medications in the 12-month baseline before index date (date of the second code). Eosinophilic granulomatosis with polyangiitis prevalence, asthma severity during the baseline period, oral corticosteroid (OCS) use, and health care utilization during the 12-month follow-up period were determined. RESULTS Overall, 88 and 604 patients were included in main cohort EGPA 1 and sensitivity analysis cohort EGPA 2, respectively; corresponding annual EGPA prevalence rates were 3.2 to 5.9 and 23.4 to 30.7 cases/million patients. Approximately 75% of patients were prescribed OCS and ~30% experienced 1 or more hospitalization; 75% in EGPA 1 and 52% in EGPA 2 with 1 or more non-OCS prescription in the 90 days before index date had severe asthma. CONCLUSIONS Eosinophilic granulomatosis with polyangiitis prevalence estimates varied based on specificity of the case definition but were generally consistent with previous country-specific estimates. Despite differences in prevalence, both cohorts displayed a generally similar, high burden of OCS use and health care utilization, highlighting the substantial disease burden among patients with EGPA and the need for specific treatments.
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Affiliation(s)
- Mugdha Gokhale
- From the Real World Evidence & Epidemiology, GlaxoSmithKline (GSK), Upper Providence, PA
| | | | - Scott Doyle
- Global Value Evidence & Outcomes, GSK, Brentford
| | | | | | - Melissa K. Van Dyke
- From the Real World Evidence & Epidemiology, GlaxoSmithKline (GSK), Upper Providence, PA
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178
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Ashman PE, Chen T, Barinsky GL, Benson B, Babu S, Bojrab DI, Svider PF. Otologic Manifestations of Eosinophilic Granulomatosis With Polyangiitis: A Systematic Review. Otol Neurotol 2021; 42:e380-e387. [PMID: 33534386 DOI: 10.1097/mao.0000000000003024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To perform a systematic review of the diagnosis, treatment, and management of patients with otologic manifestations of eosinophilic granulomatosis with polyangiitis. DATABASES REVIEWED PubMed, Embase, Cochrane. METHODS A systematic search for relevant published literature in PubMed, Cochrane Library, and EMBASE databases was done. Data was collected on demographics, otologic manifestations, specific diagnostic criteria fulfilled, common clinical, and imaging findings as well as medical and surgical treatments received. RESULTS Fifteen articles encompassing 219 patients met inclusion criteria including 8 case reports and 7 case series. The mean age was 52.8 (range of 24-70). The most common otologic presenting symptoms were hearing loss (76%), otitis media with effusion (44%), vertigo (22%), tinnitus (21%), and chronic otitis media (20%). The most common diagnostic criteria observed in these patients were paranasal sinus abnormalities (75%), asthma (66%), and eosinophilia >10% (44%). The most common treatment was systemic steroids (66%), followed by surgery (52%), with myringotomy with tube insertion (M&T) (32%) and endoscopic sinus surgery (21%) being the most prevalent. Thirty-four percent of patients received an immunosuppressive agent. Successful treatments included systemic steroids (23%), surgical modalities (13%) with M&T being the most common (7%), topical nasal steroids (12%), and cyclophosphamide (10%). CONCLUSION Hearing loss and a middle ear effusion are the most common presenting otologic manifestations of eosinophilic granulomatosis with polyangiitis. Sinonasal disease was more prevalent in patients with otologic manifestations. Primary treatment consists of systemic steroids and immunomodulation. M&T, endoscopic sinus surgery, and local steroid administration can be adjunctive measures to alleviate local disease.Level of Evidence: Level 1.
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Affiliation(s)
- Peter E Ashman
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | | | - Gregory L Barinsky
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Brian Benson
- Hackensack Meridian School of Health, Nutley
- Hackensack University Medical Center, Hackensack, New Jersey
| | - Seilesh Babu
- Michigan Ear Institute, Farmington Hills, Michigan
| | | | - Peter F Svider
- Hackensack University Medical Center, Hackensack, New Jersey
- Bergen Medical Associates, Emerson, New Jersey
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179
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Liu S, Guo L, Fan X, Zhang Z, Zhou J, Tian X, Li M, Zeng X, Wang L, Zhang F. Clinical features of central nervous system involvement in patients with eosinophilic granulomatosis with polyangiitis: a retrospective cohort study in China. Orphanet J Rare Dis 2021; 16:152. [PMID: 33789679 PMCID: PMC8010942 DOI: 10.1186/s13023-021-01780-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/16/2021] [Indexed: 01/12/2023] Open
Abstract
Background Central nervous system (CNS) involvement is extremely rare in eosinophilic granulomatosis with polyangiitis (EGPA), but is associated with a poor prognosis in the five-factor score. This study aims to elucidate the clinical features and independently associated factors of EGPA with CNS involvement. Results CNS involvement was observed in 17.3% (19/110) of EGPA patients from Peking Union Medical College Hospital between 2007 and 2019. We retrospectively reviewed their clinical data and analyzed the independently associated factors. Their mean age was 51.7 ± 11.56 years with no male/female predominance. Ischemic lesions were the most common manifestations, accounting for 63.2% of the 19 cases, followed by posterior reversible encephalopathy syndrome (36.8%), spinal cord involvement (15.8%), medulla oblongata involvement (15.8%), and intracranial hemorrhages (15.8%). Compared to the control group, patients with CNS involvement were of older age (51.7 ± 11.56 vs. 43.7 ± 13.78 years, p = 0.019) and had a higher ratio in the digestive tract involvement (52.6% vs. 28.6%, p = 0.042). Further multivariate analysis revealed that age, disease duration, and fever were the potential independent risk factors for CNS involvement of EGPA. Glucocorticoids combined with cyclophosphamide were the strategic therapy (94.7%). Intrathecal injections of dexamethasone and methotrexate were administered to 21.1% of the patients. Although seven patients relapsed during glucocorticoid reduction, seventeen patients finally achieved clinical remission. One patient died of acute intracerebral hemorrhage within one month, and another died of gastrointestinal perforation. Outcomes and cumulative survival show no significant differences between the two groups. Conclusions CNS involvement is uncommon in EGPA with various manifestations, and ischemic lesions are the most frequent. Age, disease duration, and fever are independent factors associated with CNS involvement in EGPA. The therapy of glucocorticoids combined with cyclophosphamide and intrathecal injections yields favorable responses. Acute intracranial hemorrhage and gastrointestinal perforation may be the principal causes of death.
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Affiliation(s)
- Suying Liu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, the Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, 100730, China
| | - Ling Guo
- Department of Rheumatology, Dongying People's Hospital, Dongying, 257000, Shandong Province, China
| | - Xiaoyuan Fan
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Zhaocui Zhang
- Department of Rheumatology and Clinical Immunology, Gansu Province People's Hospital, Lanzhou, 730000, Gansu Province, China
| | - Jiaxin Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, the Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, 100730, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, the Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, 100730, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, the Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, the Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, 100730, China
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, the Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, 100730, China.
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, the Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, 100730, China.
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180
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Improvement of Chronic Rhinosinusitis and Reduction of the Myeloperoxidase-Antineutrophil Cytoplasmic Antibody Titer in a Patient with Eosinophilic Granulomatosis with Polyangiitis by Additional Mepolizumab. Case Rep Rheumatol 2021; 2021:5561762. [PMID: 33859858 PMCID: PMC8024092 DOI: 10.1155/2021/5561762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/23/2021] [Accepted: 03/18/2021] [Indexed: 12/26/2022] Open
Abstract
A case of eosinophilic granulomatosis with polyangiitis (EGPA) in which chronic rhinosinusitis (CRS) was improved with a reduction in the myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) titer after the addition of mepolizumab is reported. A 55-year-old woman with EGPA receiving prednisolone 5 mg/day developed CRS with increases in the eosinophil count and the MPO-ANCA titer. Although it improved with prednisolone 15 mg/day in addition to mizoribine 150 mg/day, because azathioprine could not be taken orally due to side effects, it relapsed after prednisolone was tapered to 5 mg/day. There was no exacerbation of other vasculitis symptoms such as mononeuropathy multiplex. The patient was treated with additional mepolizumab 300 mg every 4 weeks, which resulted in the improvement of CRS and marked reductions of the eosinophil count and MPO-ANCA titer, and the reduction of prednisolone to 2 mg/day. Furthermore, even after tapering mepolizumab to 200 mg every 4 weeks, her condition remained stable without relapse of EGPA and without increases in the eosinophil count and MPO-ANCA titer. The clinical course of mepolizumab treatment in this patient suggests that the IL5-dependent inflammatory cascade is one of the factors contributing to the increase in MPO-ANCA in EGPA.
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181
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Scolding N. CNS involvement in systemic vasculitides. J Neurol Sci 2021; 424:117423. [PMID: 33840508 DOI: 10.1016/j.jns.2021.117423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/26/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022]
Abstract
Both the CNS and the PNS can be involved in almost all of the vasculitides - including the primary systemic vasculitic disorders, such as microscopic polyangiitis and polyarteritis nodosa, and in non-vasculitic systemic disorders, such as systemic lupus erythematosis and sarcoidosis. The latter diseases also include infections and toxininduced disorders - particularly drugs of abuse such as cocaine and amphetamines. Here we will summarise the spectrum of these disorders as they affect the CNS, concentrating in particular on their distinguishing clinical and investigational features.
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Affiliation(s)
- Neil Scolding
- Burden Professor of Clinical Neurosciences, University of Bristol Institute of Clinical Neurosciences, UK, Gulu University Faculty of Medicine, Uganda.
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182
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Cox SZ, Gwathmey KG. Chronic Immune-Mediated Polyneuropathies. Clin Geriatr Med 2021; 37:327-345. [PMID: 33858614 DOI: 10.1016/j.cger.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This article discusses the chronic immune-mediated polyneuropathies, a broad category of acquired polyneuropathies that encompasses chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), the most common immune-mediated neuropathy, the CIDP variants, and the vasculitic neuropathies. Polyneuropathies associated with rheumatological diseases and systemic inflammatory diseases, such as sarcoidosis, will also be briefly covered. These patients' history, examination, serum studies, and electrodiagnostic studies, as well as histopathological findings in the case of vasculitis, confirm the diagnosis and differentiate them from the more common length-dependent polyneuropathies. Prompt identification and initiation of treatment is imperative for these chronic immune-mediated polyneuropathies to prevent disability and even death.
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Affiliation(s)
- Stephen Zachary Cox
- Department of Neurology, Virginia Commonwealth University, 1101 East Marshall Street, PO Box 980599, Richmond, VA 23298, USA
| | - Kelly G Gwathmey
- Department of Neurology, Virginia Commonwealth University, 1101 East Marshall Street, PO Box 980599, Richmond, VA 23298, USA.
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183
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Réau V, Vallée A, Terrier B, Plessier A, Abisror N, Ackermann F, Benainous R, Bohelay G, Chabi-Charvillat ML, Cornec D, Desbois AC, Faguer S, Freymond N, Gaillet A, Hamidou M, Killian M, Le Jeune S, Marchetti A, Meyer G, Osorio-Perez F, Panel K, Rautou PE, Rohmer J, Simon N, Tcherakian C, Vasse M, Zuelgaray E, Lefevre G, Kahn JE, Groh M. Venous thrombosis and predictors of relapse in eosinophil-related diseases. Sci Rep 2021; 11:6388. [PMID: 33737704 PMCID: PMC7973521 DOI: 10.1038/s41598-021-85852-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/08/2021] [Indexed: 12/13/2022] Open
Abstract
Eosinophils have widespread procoagulant effects. Eosinophilic cardiovascular toxicity mostly consists of endomyocardial damage or eosinophilic vasculitis, while reported cases of venous thrombosis (VT) are scarce. We aimed to report on the clinical features and treatment outcomes of patients with unexplained VT and eosinophilia, and to identify predictors of relapse. This retrospective, multicenter, observational study included patients aged over 15 years with VT, concomitant blood eosinophilia ≥ 1G/L and without any other moderate-to-strong contributing factors for VT. Fifty-four patients were included. VT was the initial manifestation of eosinophil-related disease in 29 (54%) patients and included pulmonary embolism (52%), deep venous thrombosis (37%), hepatic (11%) and portal vein (9%) thromboses. The median [IQR] absolute eosinophil count at VT onset was 3.3G/L [1.6-7.4]. Underlying eosinophil-related diseases included FIP1L1-PDGFRA-associated chronic myeloid neoplasm (n = 4), Eosinophilic Granulomatosis with Polyangiitis (n = 9), lymphocytic (n = 1) and idiopathic (n = 29) variants of hypereosinophilic syndrome. After a median [IQR] follow-up of 24 [10-62] months, 7 (13%) patients had a recurrence of VT. In multivariate analysis, persistent eosinophilia was the sole variable associated with a shorter time to VT relapse (HR 7.48; CI95% [1.94-29.47]; p = 0.015). Long-term normalization of eosinophil count could prevent the recurrence of VT in a subset of patients with unexplained VT and eosinophilia ≥ 1G/L.
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Affiliation(s)
- Valériane Réau
- Department of Internal and Geriatric Medicine, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Créteil, France.,National Reference Center for Hypereosinophilic Syndromes, CEREO, France
| | - Alexandre Vallée
- Department of Clinical Research and Innovation (DRCI), Hôpital Foch, 92150, Suresnes, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Systemic and Autoimmune Diseases, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Aurélie Plessier
- Department of Hepatology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Noémie Abisror
- Department of Internal Medicine, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Félix Ackermann
- National Reference Center for Hypereosinophilic Syndromes, CEREO, France.,Department of Internal Medicine, Hôpital Foch, 40, rue Worth, 92151, Suresnes Cedex, France
| | - Ruben Benainous
- Department of Internal Medicine, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, Bobigny, France
| | - Gérôme Bohelay
- Department of Dermatology, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, Bobigny, France
| | | | - Divi Cornec
- Department of Rheumatology, Brest University Hospital, Brest, France
| | - Anne-Claire Desbois
- Department of Internal Medicine, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Stanislas Faguer
- Department of Nephrology, Toulouse University Hospital, Toulouse, France
| | | | - Antoine Gaillet
- National Reference Center for Hypereosinophilic Syndromes, CEREO, France.,Department of Internal Medicine, Hôpital Foch, 40, rue Worth, 92151, Suresnes Cedex, France
| | - Mohamed Hamidou
- Department of Internal Medicine, Hôtel-Dieu University Hospital, Nantes, France
| | - Martin Killian
- Department of Internal Medicine, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Sylvain Le Jeune
- Department of Internal Medicine, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, Bobigny, France
| | - Anne Marchetti
- Department of Dermatology, Lyon-Sud Hospital, Pierre-Bénite, France
| | - Guy Meyer
- Pulmonology and Intensive Care Service, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Kewin Panel
- National Reference Center for Hypereosinophilic Syndromes, CEREO, France.,Department of Internal Medicine, Hôpital Foch, 40, rue Worth, 92151, Suresnes Cedex, France
| | - Pierre-Emmanuel Rautou
- Department of Hepatology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Julien Rohmer
- National Reference Center for Hypereosinophilic Syndromes, CEREO, France.,Department of Internal Medicine, Hôpital Foch, 40, rue Worth, 92151, Suresnes Cedex, France
| | - Nicolas Simon
- Department of Internal Medicine, Grenoble Alpes University Hospital, Grenoble, France
| | | | - Marc Vasse
- Department of Clinical Biology, Foch Hospital, Suresnes, France.,UMR-S INSERM 1176, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Elina Zuelgaray
- Department of Dermatology, Saint Louis, Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Guillaume Lefevre
- National Reference Center for Hypereosinophilic Syndromes, CEREO, France.,Department of Internal Medicine, Lille University Hospital, Lille, France
| | - Jean-Emmanuel Kahn
- National Reference Center for Hypereosinophilic Syndromes, CEREO, France.,Department of Internal Medicine, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France
| | - Matthieu Groh
- National Reference Center for Hypereosinophilic Syndromes, CEREO, France. .,Department of Internal Medicine, Hôpital Foch, 40, rue Worth, 92151, Suresnes Cedex, France.
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184
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Effectiveness and safety of mepolizumab in combination with corticosteroids in patients with eosinophilic granulomatosis with polyangiitis. Arthritis Res Ther 2021; 23:86. [PMID: 33726827 PMCID: PMC7962235 DOI: 10.1186/s13075-021-02462-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 02/22/2021] [Indexed: 12/16/2022] Open
Abstract
Background Mepolizumab (MPZ), an anti-interleukin-5 antibody, is effective for the treatment of eosinophilic granulomatosis with polyangiitis (EGPA). However, its effectiveness has not been adequately evaluated in real-world clinical practice. In this study, we assessed the effectiveness and safety of MPZ (300 mg) for relapsing/refractory EGPA resistant to corticosteroids (CS) for 1 year in real-world settings. Methods We administered MPZ (300 mg) to 16 patients with relapsing/refractory EGPA resistant to CS (Post-MPZ). We also retrospectively collected data from the same patients for the 12 months before the administration of MPZ (Pre-MPZ). The primary endpoint was the 12-month remission rate after MPZ administration and the secondary endpoints were the Birmingham vasculitis activity score (BVAS), vasculitis damage index (VDI), eosinophil counts, changes in concomitant CS doses/concomitant immunosuppressant use, MPZ retention rate, and incidence of adverse events. The clinical course was compared between Pre-MPZ and Post-MPZ. Results The 12-month remission rate after the initiation of MPZ was 75%. No change was observed in BVAS, eosinophil count, or concomitant CS dose over time in the Pre-MPZ group, whereas all these parameters were significantly decreased over time in the Post-MPZ group. The number of patients using concomitant immunosuppressant also decreased over time in the Post-MPZ group. VDI did not increase in either group. The MPZ retention rate was 100% and only three patients (18.8%) had infections. Changes in BVAS, eosinophil count, and cumulative concomitant CS dose were significantly lower in the Post-MPZ group than in the Pre-MPZ group. There was no significant difference in the changes in VDI between the groups. Conclusion This study demonstrated that MPZ is effective and safe for EGPA. Furthermore, MPZ decreases disease activity, increases remission rate, and has a CS-sparing effect.
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185
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[Cortisone-free rheumatology-Vasculitides]. Z Rheumatol 2021; 80:314-321. [PMID: 33709164 DOI: 10.1007/s00393-021-00974-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2020] [Indexed: 10/21/2022]
Abstract
Glucocorticoids (GC) still represent an essential pillar of treatment in the phase of remission induction of vasculitides, which are often organ or life-threatening; however, they entail a significant potential for side effects. In the phase of remission maintenance prednisolone should be reduced to 7.5 mg/day or less. Whether a discontinuation can alway be achieved for any form of vasculitis without increasing relapse rates, is unclear. By the use of biologics, e.g. tocilizumab in giant cell arteritis (GCA), a fast tapering and discontinuation of GC seems to be more easily achievable compared to using a GC monotherapy regimen. Avacopan could in the future be an efficient agent to spare GC in the phase of remission induction in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), e.g. granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). Mepolizumab is a promising option to reduce the use of GC in eosinophilic granulomatosis with polyangiitis (EGPA).
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186
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Reply to "Idiopathic non-necrotizing eosinophilic vasculitis limited to the lung: Part of a complex spectrum". THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2455-2456. [PMID: 32620439 DOI: 10.1016/j.jaip.2020.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/09/2020] [Indexed: 11/22/2022]
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187
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Zampieri M, Emmi G, Beltrami M, Fumagalli C, Urban ML, Dei LL, Marchi A, Berteotti M, Tomberli A, Baldini K, Bettiol A, Pradella S, Silvestri E, Marchionni N, Vaglio A, Olivotto I, Prisco D. Cardiac involvement in eosinophilic granulomatosis with polyangiitis (formerly Churg-Strauss syndrome): Prospective evaluation at a tertiary referral centre. Eur J Intern Med 2021; 85:68-79. [PMID: 33358337 DOI: 10.1016/j.ejim.2020.12.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/24/2020] [Accepted: 12/08/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic vasculitis. Cardiac specific involvement (CSI) is caused by coronary artery vasculitis, but also by myocardial eosinophilic infiltration. To date, the prevalence of CSI associated with EGPA is unresolved. Aim of this study was to systematically assess the prevalence and clinical impact of CSI in a consecutive outpatient EGPA population. METHODS Between October 2018 and July 2019, we prospectively enrolled 52 consecutive EGPA patients. All underwent comprehensive evaluation including a standardized questionnaire, physical examination, 12-lead-ECG, echocardiography. Cardiac magnetic resonance and 24 h-Holter were performed as deemed clinically appropriate. Cardiac abnormalities were defined as CSI based on the likelihood of their relation to EGPA vasculitis, after exclusion of alternative diagnoses. RESULTS 52 enrolled patients, mean age 59±1 years. Thirteen of the 52 patients (25%) were classified as CSI+. CSI was characterized by myocarditis in four patients, non-scar-related regional wall motions abnormalities (RWMA) in three, apical thrombosis in two (one also had RWMA), pericarditis in three and non-atherosclerotic coronary disease (Prinzmetal angina and coronaritis) in 2. Five (38%) of the 13 CSI+ patients, presented an apical aneurysm. Peak eosinophil count at diagnosis was higher in CSI+: 8000 /μl vs CSI-: 3000 /μl, p = 0.017. Overall, 2 patients had severe LV dysfunction, 5 required urgent hospitalization and 8 required long-term cardioactive therapy. CONCLUSIONS CSI was present in one-quarter of patients, often associated with high peak eosinophils. Myocarditis, RWMA and apical aneurysms were the most common manifestations. Although rarely severe and life-threatening, CSI often required long-term cardioactive treatment.
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Affiliation(s)
- Mattia Zampieri
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Carlo Fumagalli
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lorenzo-Lupo Dei
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Alberto Marchi
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | | | - Alessia Tomberli
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Katia Baldini
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Silvia Pradella
- Radiology Unit, Careggi University Hospital, Florence, Italy
| | - Elena Silvestri
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Cardiothoracovascular Medicine, Careggi University Hospital, Florence, Italy
| | - Augusto Vaglio
- Deptartment of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, Firenze, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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188
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Olson LC, Lelli GJ, Patel SS, Magro CM. Conjunctival Eosinophilic Granulomatosis With Polyangiitis (Churg-Strauss) in a Young Adult Male With Persistent Ptosis. J Clin Rheumatol 2021; 27:e53-e58. [PMID: 30048387 DOI: 10.1097/rhu.0000000000000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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189
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Fagni F, Bello F, Emmi G. Eosinophilic Granulomatosis With Polyangiitis: Dissecting the Pathophysiology. Front Med (Lausanne) 2021; 8:627776. [PMID: 33718405 PMCID: PMC7943470 DOI: 10.3389/fmed.2021.627776] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/18/2021] [Indexed: 12/17/2022] Open
Abstract
Eosinophilic Granulomatosis with Polyangiitis (EGPA) is a rare multisystemic disease classified both amongst hypereosinophilic disorders and ANCA-associated vasculitis. Vessel inflammation and eosinophilic proliferation are the hallmarks of the disease and main effectors of organ damage. Two distinct disease phenotypes have classically been described according to ANCA-status: the ANCA-negative subset with eosinophil-driven manifestation and the ANCA-positive one with vasculitic manifestations. An analogous dichotomization has also been backed by histological findings and a distinct genetic background. EGPA is typically consider a Th2-mediated disease and blood and tissue eosinophilia represent the cornerstone of diagnosis. Besides, ANCA are known for inducing endothelial injury and vascular inflammation by activating the circulating neutrophils. Thus, the pathogenesis of EGPA seems to be mediated by two coexisting mechanisms. However, the verbatim application of this strict dualism cannot always be translated into routine clinical practice. In the present review we describe the current knowledge on the eosinophilic and ANCA-mediated aspects of EGPA pathogenesis. Finally, we review the rationale of the currently proposed EGPA dichotomy and future research perspectives.
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Affiliation(s)
| | | | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
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190
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Belhassen A, Toujani S, El Ouni A, Meddeb Z, Abdelkefi C, Larbi T, Hamzaoui S, Bouslama K. [Characteristics of cardiac involvement in eosinophilic granulomatosis with polyangiitis]. Ann Cardiol Angeiol (Paris) 2021; 71:95-98. [PMID: 33637317 DOI: 10.1016/j.ancard.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 12/29/2020] [Indexed: 11/30/2022]
Abstract
AIM OF THE STUDY Our study aimed to identify the characteristics of cardiac involvement in eosinophilic granulomatosis with polyangiitis (EGPA). METHODS We conducted a retrospective analytic study including EGPA cases diagnosed between 2000 and 2019 in an internal medicine department. Diagnosis was made according to the 1990 American College of Rheumatology criteria and the 2012 Chapel Hill Concensus. RESULTS Eleven EGPA cases were included, 64% of patients were female. Median age at diagnosis was 52 years [42-58]. Heart damage revealed EGPA in 55% of cases with a significant predominance of women (p=0.015). The main cardiac manifestations were myocarditis, ischemic cardiomyopathy due to small vessel vasculitis, cardiac tamponade and intracardiac thrombus. Cardiac magnetic resonance imaging (MRI) mainly showed subendocardial hyposignal in early infusion and late enhancement in the same areas, nodular by locations, associated with impaired left ventricle function and micro-infarctions by distal vasculitis. Cardiac damage was associated to ANCA negativity in 83.3% of cases. The median Birmingham Vasculitis Activity Score version3 (BVAS v3) was 16 [10-17]. Under conventional treatment, no relapses had occurred. The median vasculitis damage index (VDI) was 2 [1-2.3] and the mortality rate was zero after a mean follow-up of 43 months. CONCLUSION Cardiomyopathy is a frequent revealing mode of EGPA. A late onset asthma and hypereosinophilia should guide the diagnosis. As ANCA research often turns out to be negative, histological evidence is recommended in this context. The contribution of cardiac MRI in the diagnosis of EGPA remains to be defined.
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Affiliation(s)
- A Belhassen
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie.
| | - S Toujani
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
| | - A El Ouni
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
| | - Z Meddeb
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
| | - C Abdelkefi
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
| | - T Larbi
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
| | - S Hamzaoui
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
| | - K Bouslama
- Service de médecine interne, centre hospitalier universitaire Mongi-Slim, 2070 La Marsa, Tunisie
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191
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Brilland B, Vinatier E, Subra JF, Jeannin P, Augusto JF, Delneste Y. Anti-Pentraxin Antibodies in Autoimmune Diseases: Bystanders or Pathophysiological Actors? Front Immunol 2021; 11:626343. [PMID: 33664737 PMCID: PMC7921723 DOI: 10.3389/fimmu.2020.626343] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/29/2020] [Indexed: 11/16/2022] Open
Abstract
Pentraxins are soluble innate immunity receptors involved in sensing danger molecules. They are classified as short (CRP, SAP) and long pentraxin subfamilies, including the prototypic long pentraxin PTX3. Pentraxins act mainly as bridging molecules favoring the clearance of microbes and dead cells. They are also involved in many other biological processes, such as regulation of complement activation, inflammation and tissue homeostasis. Autoantibodies directed against pentraxins have been reported in various autoimmune diseases, especially in systemic lupus erythematosus and ANCA-associated vasculitis. In this review, we review the main biological characteristics and functions of pentraxins and summarize data concerning autoantibodies directed against pentraxins in the context of autoimmune diseases and discuss their potential pathological role.
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Affiliation(s)
- Benoit Brilland
- CHU Angers, Service de Néphrologie-Dialyse-Transplantation, Angers, France.,Université d'Angers, INSERM, CRCINA, Angers, France
| | - Emeline Vinatier
- Université d'Angers, INSERM, CRCINA, Angers, France.,CHU Angers, Service d'Immunologie et Allergologie, Angers, France
| | - Jean-François Subra
- CHU Angers, Service de Néphrologie-Dialyse-Transplantation, Angers, France.,Université d'Angers, INSERM, CRCINA, Angers, France
| | - Pascale Jeannin
- Université d'Angers, INSERM, CRCINA, Angers, France.,CHU Angers, Service d'Immunologie et Allergologie, Angers, France
| | - Jean-François Augusto
- CHU Angers, Service de Néphrologie-Dialyse-Transplantation, Angers, France.,Université d'Angers, INSERM, CRCINA, Angers, France
| | - Yves Delneste
- Université d'Angers, INSERM, CRCINA, Angers, France.,CHU Angers, Service d'Immunologie et Allergologie, Angers, France
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192
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Medvedev I, Podzolkov VI, Ishina TI, Pisarev MV. Case Report: A 64-Year-Old Man with 10-Year History of Eosinophilic Granulomatosis with Polyangiitis with Bronchiectasis and Severe Klebsiella pneumonia. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929224. [PMID: 33582702 PMCID: PMC7893373 DOI: 10.12659/ajcr.929224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/30/2020] [Accepted: 12/19/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare and severe progressive disease with multiple clinical manifestations and organ damage. Usually, it requires long-term monitoring of the state of many organs due to the gradual character of its manifestations. CASE REPORT We report a case of a long-term follow-up of a patient with eosinophilic granulomatosis with polyangiitis with emphasis on specific clinical features in this patient. A 64-year-old man was being followed up for 10 years. The initial diagnosis was allergic bronchial asthma; however, as new clinical signs and symptoms developed, the diagnosis of EGPA became obvious. A positive treatment response was seen, mainly manifested as reduced polyneuropathy. Meanwhile, bronchial asthma remained uncontrolled and bronchiectasis and Klebsiella pneumoniae colonization developed despite the combination treatment with prednisolone and methotrexate. Furthermore, the patient suffered a cerebral ischemic infarction. During the last hospital admission, severe uncontrolled bronchial asthma complicated with pneumonia resulted in the patient's death. CONCLUSIONS This clinical case shows the gradual development of EGPA with multiple-organ involvement, including respiratory manifestations and peripheral and central nervous system damage. Immunosuppressive treatment combined with complications of EGPA could have contributed to severe pneumonia development and death of the patient.
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Affiliation(s)
- Ivan Medvedev
- Chair of Internal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Valery I. Podzolkov
- Chair of Internal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Tatiana I. Ishina
- Chair of Internal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Mikhail V. Pisarev
- Laboratory for the Study of Advanced Simulation Technologies, V. A. Negovsky Research Institute of General Reanimatology, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation
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193
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Trivioli G, Terrier B, Vaglio A. Eosinophilic granulomatosis with polyangiitis: understanding the disease and its management. Rheumatology (Oxford) 2021; 59:iii84-iii94. [PMID: 32348510 DOI: 10.1093/rheumatology/kez570] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/15/2019] [Indexed: 12/14/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis is characterized by asthma, blood and tissue eosinophilia and small-vessel vasculitis. The clinical presentation is variable, but two main clinic-pathologic subsets can be distinguished: one hallmarked by positive ANCA and predominant 'vasculitic' manifestations (e.g. glomerulonephritis, purpura and mononeuritis multiplex) and the other by negative ANCA and prominent 'eosinophilic' manifestations (e.g. lung infiltrates and cardiomyopathy). The pathogenesis is not fully understood but probably results from the interplay between T and B cells and eosinophils. Eosinophilic granulomatosis with polyangiitis must be differentiated from several conditions, including hypereosinophilic syndromes and other small-vessel vasculitides. The overall survival is good; however, patients frequently relapse and have persistent symptoms. The recently developed monoclonal antibodies targeting B cells and eosinophilopoietic cytokines such as IL-5 are emerging as valid alternatives to conventional immunosuppressive therapies. In this review, we discuss the essential features of eosinophilic granulomatosis with polyangiitis, with particular respect to the most relevant issues concerning clinical presentation and management.
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Affiliation(s)
- Giorgio Trivioli
- Department of Biomedical Experimental and Clinical Sciences 'Mario Serio', University of Firenze, Florence, Italy
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, and Université Paris Descartes, Paris 5, Paris, France
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences 'Mario Serio', University of Firenze, Florence, Italy
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194
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Alberici F, Bonatti F, Adorni A, Daminelli G, Sinico RA, Gregorini G, Marvisi C, Fenaroli P, Peyronel F, Maritati F, Palmisano A, Urban ML, Percesepe A, Emmi G, Martorana D, Vaglio A. FCGR3B polymorphism predicts relapse risk in eosinophilic granulomatosis with polyangiitis. Rheumatology (Oxford) 2021; 59:3563-3566. [PMID: 32375167 DOI: 10.1093/rheumatology/keaa134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/19/2020] [Accepted: 02/24/2020] [Indexed: 12/29/2022] Open
Affiliation(s)
- Federico Alberici
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia.,Nephrology Unit, ASST Spedali Civili, Brescia
| | | | - Alessia Adorni
- Hematology and Clinical Immunology, Department of Medicine, University of Perugia, Perugia
| | - Giulia Daminelli
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milano, Milano
| | - Renato A Sinico
- Department of Medicine and Surgery, University of Milano Bicocca, ASST Monza, Milano/Monza
| | | | - Chiara Marvisi
- Rheumatology Unit, University of Modena and Reggio Emilia, Reggio Emilia
| | | | | | - Federica Maritati
- Nephrology, Dialysis and Renal Transplantation Unit, University Hospital "Ospedali Riuniti" of Ancona, Ancona
| | | | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Florence, Florence
| | | | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence
| | - Davide Martorana
- Unit of Medical Genetics, University Hospital of Parma, Parma.,CoreLab, Research Common Center, University Hospital of Parma, Parma
| | - Augusto Vaglio
- Department of Biomedical, Experimental and Clinical Sciences, University of Firenze.,Nephrology and Dialysis Unit, Meyer Children's Hospital, Firenze, Italy
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195
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Mekic M, Begic E, Mutevelic S, Sinancevic A. Churg-Strauss Syndrome Along with Cardiac Complications. Int J Appl Basic Med Res 2021; 11:50-52. [PMID: 33842298 PMCID: PMC8025947 DOI: 10.4103/ijabmr.ijabmr_200_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/14/2020] [Accepted: 12/28/2020] [Indexed: 11/26/2022] Open
Abstract
Churg-Strauss syndrome (CCS) or eosinophilic granulomatosis with polyangiitis is a rare condition, which is a challenge for both diagnosis and treatment in clinical work. Occurrences of cardiac complications represent a negative predictor of treatment outcome for these patients. The aim of this article is to present the diagnostic and therapeutic modality of a 33-year-old male diagnosed with? CCS. Treatment of these patients should be multidisciplinary, with a comprehensive therapeutic modality, while early diagnosis is imperative.
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Affiliation(s)
- Mevludin Mekic
- Department of Rheumatology, Clinic for Heart, Blood Vessel and Rheumatic Diseases, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina.,Department of Internal Medicine, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Edin Begic
- Department of Cardiology, General Hospital "Prim Dr. Abdulah Nakas", Sarajevo, Bosnia and Herzegovina.,Department of Pharmacology, Sarajevo Medical School, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
| | - Selma Mutevelic
- Department of Clinical Biochemistry and Immunology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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196
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Garcia-Vives E, Rodriguez-Palomares JF, Harty L, Solans-Laque R, Jayne D. Heart Disease in Eosinophilic Granulomatosis with Polyangiitis (EGPA) Patients: a screening approach proposal. Rheumatology (Oxford) 2021; 60:4538-4547. [PMID: 33493294 DOI: 10.1093/rheumatology/keab027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/11/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To define the pattern of cardiac involvement in eosinophilic granulomatosis and polyangiitis (EGPA) and propose an algorithm for heart disease screening. METHODS Retrospective study of EGPA patients attending a specialized vasculitis clinic (1989-2016). Clinical characteristics and cardiovascular evaluation (CE) results (serum troponin, ECG, echocardiography and cardiac magnetic resonance) were collected and compared according to symptoms and inflammatory cardiac disease (ICD). RESULTS 131 EGPA patients were included, of whom 96 (73%) had undergone CE. The median age was 50 [IQR 38-58] years and 36% showed ANCA+. Asthma preceded diagnosis by a median of 97 [36-240] months. Among the 96 patients who underwent CE, 43% were symptomatic, being dyspnea (47%) and chest pain (29%) the predominant symptoms. In asymptomatic patients, CE reported abnormalities in 45% of cases with a subsequent earlier diagnosis (4 vs 11 months). Overall, 27 patients had EGPA-related ICD (rICD) that was already present at diagnosis in 20 cases, preceded it in 2 cases and developed later in 5. EGPA-rICD patients were younger (46 vs 50 years; p= 0.04), had more frequently abnormal ECG (30.8% vs 2.1%; p< 0.001), negative ANCA (85% vs 69%; NS), higher BVAS score (3 vs 1; p= 0.005), higher eosinophil count (5.60 vs 1.60x109/l; p= 0.029) and higher C reactive protein (52 vs 15 mg/l; p= 0.017). Overall, 11% of cases with EGPA-rICD were asymptomatic. CONCLUSION In our study, 45% of asymptomatic patients had an abnormal baseline cardiac evaluation, which allowed an earlier diagnosis of cardiac disease. We recommend prompt cardiac screening in all EGPA patients, instead of a symptoms-guided algorithm.
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Affiliation(s)
- Eloi Garcia-Vives
- Autoimmune Systemic Diseases Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - J F Rodriguez-Palomares
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, CIBER-CV, Vall d'Hebrón Institut de recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Len Harty
- Rheumatology Department, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Roser Solans-Laque
- Autoimmune Systemic Diseases Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - David Jayne
- Nephrology Department, Addenbrooke's Hospital, Cambridge, United Kingdom
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197
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Liu S, Guo L, Zhang Z, Li M, Zeng X, Wang L, Liu Y, Zhang F. Cardiac manifestations of eosinophilic granulomatosis with polyangiitis from a single-center cohort in China: clinical features and associated factors. Ther Adv Chronic Dis 2021; 12:2040622320987051. [PMID: 33613936 PMCID: PMC7841702 DOI: 10.1177/2040622320987051] [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] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/18/2020] [Indexed: 12/26/2022] Open
Abstract
Background: Cardiac manifestations are common and life-threatening in eosinophilic granulomatosis with polyangiitis (EGPA), which remains poorly studied in China. We aim to investigate its clinical features, associated factors, treatment, and outcomes. Methods: We reviewed the clinical records of 110 EGPA patients and examined the independent factors associated with cardiac manifestations using multivariate logistic regression. Receiver operating characteristic curves determined the cut-off values, and survival was calculated via Kaplan–Meier curves. Results: Cardiac involvement was present in 36.4% (40/110) of EGPA patients, which mainly manifested as pericardial effusion (16.4%, 18/110), myocardial involvement (13.6%, 15/110), and heart failure (8.2%, 9/110). The mean age was 42.1 ± 14.23 years with no female/male predominance. Compared with the cardiac-unaffected group, the cardiac-affected group showed a lower rate of biopsy-proved vasculitis (0% versus 20%, p = 0.002). The eosinophil count [odds ratio (OR) = 1.142, 95% confidence interval (CI) 1.029–1.267] was independently associated with cardiac manifestations in EGPA, with a cut-off value of 3.66 × 109/L [area under the curve (AUC) = 0.692, p = 0.001]. Regarding treatment, the cardiac-affected group displayed a higher ratio of glucocorticoid pulse combined with intravenous cyclophosphamide (CYC-IV) (40% versus 21.4%, p = 0.037), and intravenous immunoglobulin combined with glucocorticoid plus CYC-IV (17.5% versus 4.3%, p = 0.035) than the control group. Outcomes (p = 0.131) and survival (p = 0.1972) were not significantly different between the groups. Conclusion: In this single-center Chinese EGPA cohort, cardiac manifestations are observed in 36.4% of patients, which primarily presents as myocardial involvement, pericardial effusion, and heart failure, independently associated with eosinophil count. Glucocorticoid combined with cyclophosphamide is the treatment cornerstone for EGPA patients with cardiac manifestations.
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Affiliation(s)
- Suying Liu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, The Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Ling Guo
- Department of Rheumatology, Dongying People's Hospital, Dongying, Shandong Province, China
| | - Zhaocui Zhang
- Department of Rheumatology and Clinical Immunology, Gansu Province People's Hospital, Lanzhou, Gansu Province, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, The Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, The Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing, China
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, The Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Yongtai Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, The Ministry of Education Key Laboratory, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing 100730, China
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198
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Mohamed H, CE Ó Mathúna E, Elbardesy H, Shorten G. Anaesthetic management of a patient with eosinophilic granulomatosis with polyangiitis for internal fixation of a fractured femur. BMJ Case Rep 2021; 14:14/1/e239052. [PMID: 33419755 PMCID: PMC7798413 DOI: 10.1136/bcr-2020-239052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare disease with an estimated annual incidence of 0.5-6.8 per million. It is characterised by necrotising vasculitis with multiorgan eosinophilic infiltration. Pulmonary manifestations are the most common presentation of EGPA, and cardiac complications are the most common cause of death. Anaesthetic management of EGPA is challenging due to perioperative pulmonary complications, multiorgan involvement and greater risk of cholinesterase enzyme deficiency. We are reporting the anaesthetic management of a 58-year-old woman, diagnosed with EGPA 3 years ago, who underwent urgent intramedullary nail insertion for a femur fracture. The anaesthetic technique comprised femoral nerve block and spinal anaesthesia, thereby avoiding (1) the need for upper airway manipulation, (2) potential adverse effects of anticholinesterase drugs (for reversal of neuromuscular blockade) and (3) histamine release associated with morphine administration perioperatively. Surgery and anaesthesia were uneventful.
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Affiliation(s)
- Hassan Mohamed
- Department of Anaesthesia, Intensive Care and Pain Management, Faculty of Medicine, Cairo University Kasr Alainy, Cairo, Egypt,Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Euan CE Ó Mathúna
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Hany Elbardesy
- Department of Orthopaedics, Cork University, Cork, Ireland
| | - George Shorten
- Department of Anaesthesia and Intensive Care, Cork University Hospital, Cork, Ireland,Department of Anaesthesia, University College Cork, Cork, Ireland
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199
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Suzuki M, Nakazono A, Morita S, Fukuda A, Honma A, Suzuki T, Kimura S, Nakamaru Y, Homma A. Comparison of clinical characteristics of the nasal manifestations of eosinophilic granulomatosis with polyangiitis (EGPA) and eosinophilic chronic rhinosinusitis (ECRS). Allergol Int 2021; 70:143-144. [PMID: 32636058 DOI: 10.1016/j.alit.2020.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/23/2020] [Accepted: 05/13/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Masanobu Suzuki
- Department of Otolaryngology-Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Akira Nakazono
- Department of Otolaryngology-Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Shinya Morita
- Department of Otolaryngology-Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Atsushi Fukuda
- Department of Otolaryngology-Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Aya Honma
- Department of Otolaryngology-Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Takayoshi Suzuki
- Department of Otolaryngology-Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Shogo Kimura
- Department of Otolaryngology-Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Yuji Nakamaru
- Department of Otolaryngology-Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Hokkaido, Japan.
| | - Akihiro Homma
- Department of Otolaryngology-Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
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200
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Oh Y, Han M, Park HK, Jo EJ. Eosinophilic granulomatosis with polyangiitis misdiagnosed as non-ST-segment elevation myocardial infarction: A case report. ALLERGY ASTHMA & RESPIRATORY DISEASE 2021. [DOI: 10.4168/aard.2021.9.1.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Yeseul Oh
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Miyeun Han
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Hye-Kyung Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Eun-Jung Jo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
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