201
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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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202
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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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203
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Papo M, Sinico RA, Teixeira V, Venhoff N, Urban ML, Iudici M, Mahrhold J, Locatelli F, Cassone G, Schiavon F, Seeliger B, Neumann T, Kroegel C, Groh M, Marvisi C, Samson M, Barba T, Jayne D, Troilo A, Thiel J, Hellmich B, Monti S, Montecucco C, Salvarani C, Kahn JE, Bonnotte B, Durel CA, Puéchal X, Mouthon L, Guillevin L, Emmi G, Vaglio A, Terrier B. Significance of PR3-ANCA positivity in eosinophilic granulomatosis with polyangiitis (Churg-Strauss). Rheumatology (Oxford) 2020; 60:4355-4360. [PMID: 33347592 DOI: 10.1093/rheumatology/keaa805] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/27/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Only a third of patients with eosinophilic granulomatosis with polyangiitis (EGPA) are ANCA-positive, mainly directed against MPO. ANCA directed against PR3 are rarely found in EGPA. We aimed to examine the significance of PR3-ANCA in EGPA. METHODS We set up a retrospective European multicentre cohort including 845 patients. Baseline characteristics and outcomes were analysed and compared according to ANCA status. RESULTS ANCA status was available for 734 patients: 508 (69.2%) ANCA-negative, 210 (28.6%) MPO-ANCA and 16 (2.2%) PR3-ANCA. At baseline, PR3-ANCA patients, compared with those with MPO-ANCA and ANCA-negative, less frequently had active asthma (69% vs 91% and 93%, P = 0.003, respectively) and peripheral neuropathy (31% vs 71% and 47%, P < 0.0001), more frequently had cutaneous manifestations (63% vs 38% and 34%, P = 0.03) and pulmonary nodules (25% vs 10% and 8%, P = 0.046), and lower median eosinophil count (1450 vs 5400 and 3224/mm3, P < 0.0001). Vasculitis relapse-free survival was shorter for PR3-ANCA (hazard ratio 6.05, P = 0.005) and MPO-ANCA patients (hazard ratio 1.88, P = 0.0002) compared with ANCA-negative patients. CONCLUSION PR3-ANCA EGPA patients differ from those with MPO-ANCA and negative ANCA, and share clinical features with granulomatosis with polyangiitis. This suggests that PR3-ANCA EGPA could be a particular form of PR3-ANCA-associated vasculitis.
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Affiliation(s)
- Matthias Papo
- Department of Internal Medicine, Cochin Hospital, National Referral Center for Rare Systemic Autoimmune Diseases, Paris University, Paris, France
| | - Renato A Sinico
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Milano/Monza, Italy
| | - Vítor Teixeira
- Department of Medicine, University of Cambridge, Cambridge, UK.,Department of Rheumatology, Centro Hospitalar Universitário do Algarve, Portugal
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Maria-Letizia Urban
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Michele Iudici
- Department of Internal Medicine, Cochin Hospital, National Referral Center for Rare Systemic Autoimmune Diseases, Paris University, Paris, France.,Rheumatology Unit, Geneva University Hospitals, Geneva, Switzerland
| | - Juliane Mahrhold
- Department of Internal Medicine, Rheumatology and Immunology, Vasculitis-Center Tübingen-Kirchheim, Medius Klinik Kirchheim, University of Tübingen, Kirchheim-Teck, Germany
| | - Francesco Locatelli
- Department of Rheumatology, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Giulia Cassone
- Clinical and Experimental Medicine PhD Program, Azienda USL-IRCCS di Reggio Emilia and Università di Modena and Reggio Emilia, Italy
| | - Franco Schiavon
- Operative Unit of Rheumatology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Benjamin Seeliger
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Thomas Neumann
- Department of Rheumatology, Clinic of Internal Medicine II I, Jena University Hospital, Jena, Germany.,Division of Rheumatology, Immunology and Rehabilitation, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Claus Kroegel
- Department of Pneumology and Allergology, Clinic of Internal Medicine I, Jena University Hospital, Jena, Germany
| | - Matthieu Groh
- Service de Médecine Interne, Centre de Référence des Syndromes Hyperéosinophiliques-CEREO, Hôpital Foch, Université Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Chiara Marvisi
- Rheumatology Unit Università di Modena and Reggio Emilia, Modena, Italy
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, François-Mitterrand Teaching Hospital, University of Bourgogne-Franche-Comté, Dijon, France
| | - Thomas Barba
- Department of Internal Medicine, Hôpital Edouard Herriot, Lyon, France
| | - David Jayne
- Department of Rheumatology, Centro Hospitalar Universitário do Algarve, Portugal
| | - Arianna Troilo
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Jens Thiel
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | | | - Sara Monti
- Department of Rheumatology, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Carlomaurizio Montecucco
- Department of Rheumatology, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Carlo Salvarani
- Azienda USL-IRCCS di Reggio Emilia, Università di Modena and Reggio Emilia
| | - Jean-Emmanuel Kahn
- Service de Médecine Interne, Centre de Référence des Syndromes Hyperéosinophiliques-CEREO, Hôpital Foch, Université Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Bernard Bonnotte
- Department of Internal Medicine and Clinical Immunology, François-Mitterrand Teaching Hospital, University of Bourgogne-Franche-Comté, Dijon, France
| | | | - Xavier Puéchal
- Department of Internal Medicine, Cochin Hospital, National Referral Center for Rare Systemic Autoimmune Diseases, Paris University, Paris, France
| | - Luc Mouthon
- Department of Internal Medicine, Cochin Hospital, National Referral Center for Rare Systemic Autoimmune Diseases, Paris University, Paris, France
| | - Loïc Guillevin
- Department of Internal Medicine, Cochin Hospital, National Referral Center for Rare Systemic Autoimmune Diseases, Paris University, Paris, France
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Augusto Vaglio
- Department of Internal Medicine, Cochin Hospital, National Referral Center for Rare Systemic Autoimmune Diseases, Paris University, Paris, France.,Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Milano/Monza, Italy
| | - Benjamin Terrier
- Department of Internal Medicine, Cochin Hospital, National Referral Center for Rare Systemic Autoimmune Diseases, Paris University, Paris, France
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204
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Michailidou D, Mustelin T, Lood C. Role of Neutrophils in Systemic Vasculitides. Front Immunol 2020; 11:619705. [PMID: 33391289 PMCID: PMC7774018 DOI: 10.3389/fimmu.2020.619705] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/18/2020] [Indexed: 12/20/2022] Open
Abstract
Neutrophils and neutrophil extracellular traps (NETs) contribute to the pathogenesis of many autoimmune diseases, including vasculitis. Though neutrophils, and NETs, can break self-tolerance by being a source of autoantigens for autoantibodies in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, playing a key role in driving the autoimmune response, the role of neutrophils and NETs in large vessel vasculitis, including giant cell arteritis (GCA), is not well understood. In this review, we summarize the current insight into molecular mechanisms contributing to neutrophil-mediated pathology in small and medium vessel vasculitis, as well as provide potential translational perspectives on how neutrophils, and NETs, may partake in large vessel vasculitis, a rare disease entity of unclear pathogenesis.
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Affiliation(s)
- Despina Michailidou
- Division of Rheumatology, University of Washington, Seattle, WA, United States
| | - Tomas Mustelin
- Division of Rheumatology, University of Washington, Seattle, WA, United States
| | - Christian Lood
- Division of Rheumatology, University of Washington, Seattle, WA, United States
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205
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Myocardial involvement in eosinophilic granulomatosis with polyangiitis evaluated with cardiopulmonary magnetic resonance. Int J Cardiovasc Imaging 2020; 37:1371-1381. [PMID: 33211241 PMCID: PMC8026437 DOI: 10.1007/s10554-020-02091-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/27/2020] [Indexed: 01/09/2023]
Abstract
Patients with eosinophilic granulomatosis with polyangiitis (EGPA) most commonly die from cardiac causes, however, cardiac involvement remains poorly characterised and the relationship between cardiac and pulmonary disease is not known. This study aimed to characterise myocardial and pulmonary manifestations of EGPA, and their relationship. Prospective comprehensive cardiopulmonary investigation, including a novel combined cardiopulmonary magnetic resonance imaging (MRI) technology, was performed in 13 patients with stable EGPA. Comparison was made with 11 prospectively recruited matched healthy volunteers. Stable EGPA was associated with focal replacement and diffuse interstitial myocardial fibrosis (myocardial extracellular volume 26.9% vs. 24.7%; p = 0.034), which drove a borderline increase in left ventricular mass (56 ± 9 g/m2 vs. 49 ± 8 g/m2; p = 0.065). Corrected QT interval was significantly prolonged and was associated with the severity of myocardial fibrosis (r = 0.582, p = 0.037). Stable EGPA was not associated with increased myocardial capillary permeability or myocardial oedema. Pulmonary tissue perfusion and capillary permeability were normal and there was no evidence of pulmonary tissue oedema or fibrosis. Forced expiratory volume in one second showed a strong inverse relationship with myocardial fibrosis (r = -0.783, p = 0.038). In this exploratory study, stable EGPA was associated with focal replacement and diffuse interstitial myocardial fibrosis, but no evidence of myocardial or pulmonary inflammation or pulmonary fibrosis. Myocardial fibrosis was strongly associated with airway obstruction and abnormal cardiac repolarisation. Further investigation is required to determine the mechanisms underlying the association between heart and lung disease in EGPA and whether an immediate immunosuppressive strategy could prevent myocardial fibrosis formation.
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206
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Arnold S, Deja M, Nitschke M, Bohnet S, Wallis S, Humrich JY, Riemekasten G, Steinhoff J, Lamprecht P. Extracorporeal membrane oxygenation in ANCA-associated vasculitis. Autoimmun Rev 2020; 20:102702. [PMID: 33188916 DOI: 10.1016/j.autrev.2020.102702] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/19/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Sabrina Arnold
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Maria Deja
- Department of Anaesthesiology and Intensive Care, University of Lübeck, Lübeck, Germany
| | - Martin Nitschke
- Department of Nephrology, University of Lübeck, Lübeck, Germany
| | - Sabine Bohnet
- Department of Pulmonology, University of Lübeck, Lübeck, Germany
| | - Sönke Wallis
- Department of Pulmonology, University of Lübeck, Lübeck, Germany
| | - Jens Y Humrich
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Gabriela Riemekasten
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | | | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany.
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207
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Nanzer AM, Dhariwal J, Kavanagh J, Hearn A, Fernandes M, Thomson L, Roxas C, Green L, D'Ancona G, Agarwal S, Kent BD, Jackson DJ. Steroid-sparing effects of benralizumab in patients with eosinophilic granulomatosis with polyangiitis. ERJ Open Res 2020; 6:00451-2020. [PMID: 33263051 PMCID: PMC7682702 DOI: 10.1183/23120541.00451-2020] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/17/2020] [Indexed: 12/12/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis characterised by asthma, chronic rhinosinusitis and blood eosinophilia, which may be accompanied by neurological, cardiac, cutaneous and renal involvement [1]. Oral corticosteroids (OCS) are the most frequently used drugs to control eosinophilic inflammation and symptoms. Persistent symptoms or relapses are common, however, and many patients are at risk of developing long-term complications from systemic steroid therapy [2]. The ability of other immunosuppressant agents to achieve consistent disease control or to reduce maintenance OCS (mOCS) requirements appears to be limited [3]. Benralizumab reduces oral corticosteroid requirements in patients with EGPA and leads to improved patient-reported outcome measureshttps://bit.ly/2GI0vhf
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Affiliation(s)
- Alexandra M Nanzer
- Guy's and St Thomas' NHS Foundation Trust, Thoracic Medicine, Guy's Severe Asthma Service, London, UK.,School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Jaideep Dhariwal
- Guy's and St Thomas' NHS Foundation Trust, Thoracic Medicine, Guy's Severe Asthma Service, London, UK
| | - Joanne Kavanagh
- Guy's and St Thomas' NHS Foundation Trust, Thoracic Medicine, Guy's Severe Asthma Service, London, UK.,School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Andrew Hearn
- Guy's and St Thomas' NHS Foundation Trust, Thoracic Medicine, Guy's Severe Asthma Service, London, UK.,School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Mariana Fernandes
- Guy's and St Thomas' NHS Foundation Trust, Thoracic Medicine, Guy's Severe Asthma Service, London, UK
| | - Louise Thomson
- Guy's and St Thomas' NHS Foundation Trust, Thoracic Medicine, Guy's Severe Asthma Service, London, UK
| | - Cris Roxas
- Guy's and St Thomas' NHS Foundation Trust, Thoracic Medicine, Guy's Severe Asthma Service, London, UK
| | - Linda Green
- Guy's and St Thomas' NHS Foundation Trust, Thoracic Medicine, Guy's Severe Asthma Service, London, UK
| | - Grainne D'Ancona
- Guy's and St Thomas' NHS Foundation Trust, Thoracic Medicine, Guy's Severe Asthma Service, London, UK
| | - Sangita Agarwal
- Dept of Rheumatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Brian D Kent
- Guy's and St Thomas' NHS Foundation Trust, Thoracic Medicine, Guy's Severe Asthma Service, London, UK
| | - David J Jackson
- Guy's and St Thomas' NHS Foundation Trust, Thoracic Medicine, Guy's Severe Asthma Service, London, UK.,School of Immunology & Microbial Sciences, King's College London, London, UK
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208
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Barry J, Gadre A, Akuthota P. Hypersensitivity pneumonitis, allergic bronchopulmonary aspergillosis and other eosinophilic lung diseases. Curr Opin Immunol 2020; 66:129-135. [PMID: 33166785 DOI: 10.1016/j.coi.2020.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 10/04/2020] [Indexed: 10/23/2022]
Abstract
Hypersensitivity pneumonitis (HP) is traditionally classified into acute, subacute and chronic forms. A high index of suspicion and a detailed investigation into the patient's environment is the key to diagnosis and treatment of HP. Eosinophilic lung diseases can be broadly categorized as idiopathic (acute eosinophilic pneumonia, chronic eosinophilic pneumonia, eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndromes), those with known cause (allergic bronchopulmonary aspergillosis, drugs, parasitic and non-parasitic infections), and those associated with other known lung diseases (asthma, interstitial lung diseases and lung cancers). A detailed review of drug intake, toxin exposures, and travel history is essential in the differential diagnosis of eosinophilic lung diseases.
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Affiliation(s)
- Jeffrey Barry
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, La Jolla, CA, United States
| | - Abhishek Gadre
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, La Jolla, CA, United States
| | - Praveen Akuthota
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, La Jolla, CA, United States.
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209
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Nishi R, Koike H, Ohyama K, Fukami Y, Iijima M, Sobue G, Katsuno M. Association Between IL-5 Levels and the Clinicopathologic Features of Eosinophilic Granulomatosis With Polyangiitis. Neurology 2020; 96:226-229. [PMID: 33109625 DOI: 10.1212/wnl.0000000000011142] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/15/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ryoji Nishi
- From the Department of Neurology (R.N., H.K., K.O., Y.F., M.I., M.K.), Nagoya University Graduate School of Medicine; Department of Neurology (K.O.), Okazaki City Hospital; and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Haruki Koike
- From the Department of Neurology (R.N., H.K., K.O., Y.F., M.I., M.K.), Nagoya University Graduate School of Medicine; Department of Neurology (K.O.), Okazaki City Hospital; and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan.
| | - Ken Ohyama
- From the Department of Neurology (R.N., H.K., K.O., Y.F., M.I., M.K.), Nagoya University Graduate School of Medicine; Department of Neurology (K.O.), Okazaki City Hospital; and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Yuki Fukami
- From the Department of Neurology (R.N., H.K., K.O., Y.F., M.I., M.K.), Nagoya University Graduate School of Medicine; Department of Neurology (K.O.), Okazaki City Hospital; and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Masahiro Iijima
- From the Department of Neurology (R.N., H.K., K.O., Y.F., M.I., M.K.), Nagoya University Graduate School of Medicine; Department of Neurology (K.O.), Okazaki City Hospital; and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Gen Sobue
- From the Department of Neurology (R.N., H.K., K.O., Y.F., M.I., M.K.), Nagoya University Graduate School of Medicine; Department of Neurology (K.O.), Okazaki City Hospital; and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Masahisa Katsuno
- From the Department of Neurology (R.N., H.K., K.O., Y.F., M.I., M.K.), Nagoya University Graduate School of Medicine; Department of Neurology (K.O.), Okazaki City Hospital; and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan.
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210
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Nagy G, Csípő I, Tarr T, Szűcs G, Szántó A, Bubán T, Sipeki N, Szekanecz Z, Papp M, Kappelmayer J, Antal-Szalmás P. Anti-neutrophil cytoplasmic antibody testing by indirect immunofluorescence: Computer-aided versus conventional microscopic evaluation of routine diagnostic samples from patients with vasculitis or other inflammatory diseases. Clin Chim Acta 2020; 511:117-124. [PMID: 33002474 DOI: 10.1016/j.cca.2020.09.031] [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: 02/06/2020] [Revised: 08/29/2020] [Accepted: 09/21/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Detection of anti-neutrophil cytoplasmic antibodies (ANCA) by indirect immunofluorescence assays (IFA) is of diagnostic importance in vasculitides and some other inflammatory diseases. Automation of IFA may be beneficial in high-throughput clinical laboratories. An analytical appraisal of the EUROPattern (EPa) automated microscope and image analysis system has not been reported in a routine clinical laboratory setting testing samples from both vasculitis and non-vasculitis patients. METHODS Results of EPa and on-screen ANCA pattern recognition of 568 consecutive routine serum samples were compared to those of conventional visual evaluation. RESULTS Agreement of discrimination between negative and non-negative samples was 86.1% comparing EPa and conventional reading, and it increased to 96.7% after on-screen user validation. Importantly, from the 334 samples classified as negative by EPa 328 (98.2%) were also negative by conventional evaluation. Pattern recognition showed 'moderate' agreement between classical microscopic and EPa analysis (κ = 0.446) and 'very good' agreement after user validation (κ = 0.900). Misclassification by EPa was dominantly due to the presence of anti-nuclear/cytoplasmic antibodies (incorrect pattern, 80/568) and the lower fluorescence cut-off of the automated microscope (false positives, 73/568). CONCLUSIONS Automated ANCA testing by EPa is a reliable alternative of classical microscopic evaluation, though classification of sera needs correction by trained personnel during on-screen validation.
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Affiliation(s)
- Gábor Nagy
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - István Csípő
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tünde Tarr
- Institute of Internal Medicine, Department of Clinical Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gabriella Szűcs
- Institute of Internal Medicine, Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Antónia Szántó
- Institute of Internal Medicine, Department of Clinical Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tamás Bubán
- Institute of Internal Medicine, Department of Gastroenterology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Nóra Sipeki
- Institute of Internal Medicine, Department of Gastroenterology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szekanecz
- Institute of Internal Medicine, Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Mária Papp
- Institute of Internal Medicine, Department of Gastroenterology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Péter Antal-Szalmás
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
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211
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Rosenberg CE, Khoury P. Approach to Eosinophilia Presenting With Pulmonary Symptoms. Chest 2020; 159:507-516. [PMID: 33002503 DOI: 10.1016/j.chest.2020.09.247] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/14/2020] [Accepted: 09/18/2020] [Indexed: 12/17/2022] Open
Abstract
Eosinophilia with pulmonary involvement is characterized by the presence of peripheral blood eosinophilia, typically ≥500 cells/mm3, by pulmonary symptoms and physical examination findings that are nonspecific, and by radiographic evidence of pulmonary disease and is further supported by histopathologic evidence of tissue eosinophilia in a lung or pleura biopsy specimen and/or increased eosinophils in BAL fluid, usually >10%. Considering that there are a variety of underlying causes of eosinophilia with pulmonary manifestations and overlapping clinical, laboratory, and radiologic features, it is essential to approach the evaluation of eosinophilia with pulmonary findings systematically. In this review, we will describe a case presentation and discuss the differential diagnosis, a directed approach to the diagnostic evaluation and supporting literature, the current treatment strategies for pulmonary eosinophilia syndromes, and the levels of evidence underlying the recommendations, where available. Overall, optimal management of eosinophilic lung disease presentations are directed at the underlying cause when identifiable, and the urgency of treatment may be guided by the presence of severe end-organ involvement or life-threatening complications. When an underlying cause is not easily attributable, management of eosinophilia with pulmonary involvement largely relies on eosinophil-directed interventions, for which biologic therapies are increasingly being used.
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Affiliation(s)
- Chen E Rosenberg
- Department of Pediatrics, Division of Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Paneez Khoury
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.
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212
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Alam L, Lasam G, Fishberg R. Pericardial effusion with tamponade – an uncommon presentation leading to the diagnosis of eosinophilic granulomatosis polyangiitis: A case report. World J Cardiol 2020; 12:460-467. [PMID: 33014293 PMCID: PMC7509990 DOI: 10.4330/wjc.v12.i9.460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/02/2020] [Accepted: 09/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Eosinophilic granulomatosis polyangiitis (EGPA) is a small vessel necrotizing vasculitis that commonly presents as peripheral eosinophilia and asthma; however, it can rarely manifest with cardiac involvement such as pericarditis and cardiac tamponade. Isolated pericardial tamponade presenting as the initial symptom of EGPA is exceedingly rare. Early diagnosis and appropriate treatment are crucial to prevent life-threatening outcomes.
CASE SUMMARY 52-year-old woman with no past medical history presented with progressive dyspnea and dry cough. On physical exam she had a pericardial friction rub and bilateral rales. Vital signs were notable for tachycardia at 119 beats per minute and hypoxia with 89% oxygen saturation. On laboratory exam, she had 45% peripheral eosinophilia, troponin elevation of 1.1 ng/mL and N-terminal prohormone of brain natriuretic peptide of 2101 pg/mL. TTE confirmed a large pericardial effusion and tamponade physiology. She underwent urgent pericardial window procedure. Pericardial and lung biopsy demonstrated eosinophilic infiltration. Based on the American College of Radiology guidelines, the patient was diagnosed with EGPA which manifested in its rare form of cardiac tamponade. She was treated with steroid taper and mepolizumab.
CONCLUSION This case highlights that when isolated pericardial involvement occurs in EGPA, diagnosis is recognized by performing pericardial biopsy demonstrating histopathologic evidence of eosinophilic infiltration.
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Affiliation(s)
- Loba Alam
- Department of Medicine, Atlantic Health System-Overlook Medical Center, Summit, NJ 07901, United States
| | - Glenmore Lasam
- Department of Cardiology, Icahn School of Medicine, Mount Sinai Heart at Mount Sinai Morningside, New York, NY 10025, United States
| | - Robert Fishberg
- Department of Cardiology, Atlantic Health System Overlook, Summit, NJ 07901, United States
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213
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Pazzola G, Pipitone N, Salvarani C. Cardiac involvement in the adult primary vasculitides. Expert Rev Clin Immunol 2020; 16:985-991. [PMID: 32954889 DOI: 10.1080/1744666x.2021.1823219] [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] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Heart involvement in vasculitis is rare, but potentially severe. The ascertainment of cardiac disease in vasculitis is complex and requires an integrated multidisciplinary approach involving the Rheumatologist, Radiologist, Cardiologist, and Heart surgeon. AREAS COVERED the authors searched PubMed using the keywords 'heart'[Mesh] and vasculitis"[Mesh]. EXPERT OPINION Virtually any vasculitis can affect the heart, but cardiac involvement is more common in some vasculitides such as Takayasu arteritis, polyarteritis nodosa, and eosinophilic granulomatosis with polyangiitis. Immunosuppressive treatment and when indicated surgery can improve the prognosis.
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Affiliation(s)
- Giulia Pazzola
- Rheumatology Unit, Department of Internal Medicine, Azienda USL-IRCCS di Reggio Emilia e Università di Modena e Reggio Emilia , Reggio Emilia, Italy
| | - Nicolò Pipitone
- Rheumatology Unit, Department of Internal Medicine, Azienda USL-IRCCS di Reggio Emilia e Università di Modena e Reggio Emilia , Reggio Emilia, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Department of Internal Medicine, Azienda USL-IRCCS di Reggio Emilia e Università di Modena e Reggio Emilia , Reggio Emilia, Italy
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214
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Zhang X, Furth EE, Tondon R. Vasculitis Involving the Gastrointestinal System Is Often Incidental but Critically Important. Am J Clin Pathol 2020; 154:536-552. [PMID: 32789454 DOI: 10.1093/ajcp/aqaa083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES This study was aimed to investigate the significance of unexpected vasculitis identified in gastrointestinal (GI) specimens by determining its prevalence and correlation with clinical outcomes. METHODS GI specimens with histologic evidence of vasculitis were identified in our pathology database over a 10-year period (January 2008 to August 2018). Clinical history, treatment, and follow-up were reviewed. RESULTS Of the 131,367 GI pathology cases received over the 10-year study period, 29 (0.02%) cases showed histologic evidence of GI vasculitis. The majority (69%, 20/29) were not clinically suspected. Of these, 20% (4/20) of patients were subsequently diagnosed with systemic vasculitis. During the mean follow-up period of 34.0 months, 24% (4/17) of the patients with this unexpected diagnosis died as the result of direct complications of GI vasculitis. We also found that 95% of cases with unexpected vasculitis in their GI pathology specimens were communicated in a timely manner to the ordering physicians, which necessitated the immediate initiation of additional workups in 85% of these patients. CONCLUSIONS The GI involvement of vasculitis is rarely encountered by pathologists, but its diagnosis carries tremendous clinical significance with a high mortality rate. Therefore, timely communication is highly recommended for the early diagnosis and treatment of this disease.
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Affiliation(s)
- Xiaoming Zhang
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Emma Elizabeth Furth
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Rashmi Tondon
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
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215
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Micheletti RG, Chiesa Fuxench Z, Craven A, Watts RA, Luqmani RA, Merkel PA. Cutaneous Manifestations of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Rheumatol 2020; 72:1741-1747. [PMID: 32419292 DOI: 10.1002/art.41310] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 05/05/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Cutaneous manifestations of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA), are poorly characterized. This report describes the dermatologic features of AAV and their association with systemic manifestations of vasculitis. METHODS A cross-sectional study identifying and comparing the cutaneous manifestations of AAV was performed using data from a large, international, collaborative effort in order to collect comprehensive clinical data on patients with vasculitis. RESULTS Data from 1,184 patients with AAV from 130 centers worldwide were available. Cutaneous manifestations were common in all AAV subtypes: GPA (223 of 656, or 34%), MPA (85 of 302, or 28%), and EGPA (106 of 226, or 47%). The most frequent cutaneous manifestation in AAV (all types) was petechiae/purpura, which was observed in 181 patients (15%). Allergic and nonspecific manifestations, such as pruritus, urticaria, and maculopapular rash, were more common in EGPA than in other disease subtypes (all P < 0.01). Skin biopsy, while underutilized (performed in 22-44% of patients), was frequently found to be an effective test suitable for diagnosis of AAV (diagnostic in 68-94% of patients). Compared to patients without cutaneous manifestations, those with skin lesions more frequently had severe systemic manifestations of vasculitis (such as alveolar hemorrhage and glomerulonephritis), specifically patients with GPA or EGPA and cytoplasmic/anti-proteinase 3 (anti-PR3) ANCA-positive or ANCA-negative patients (hazard ratio >1.9 for all), but not those with MPA or perinuclear/antimyeloperoxidase ANCAs. CONCLUSION Cutaneous manifestations are common and varied in AAV and are associated with disease severity in patients with GPA, EGPA, cytoplasmic/anti-PR3 ANCA, or ANCA-negative disease. These findings underscore the potential diagnostic and prognostic importance of the cutaneous examination in the evaluation and management of AAV.
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Affiliation(s)
| | | | | | - Richard A Watts
- University of Oxford, Oxford, and Norwich Medical School, University of East Anglia, Norwich, UK
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216
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Sato M, Yoshida Y, Sugimoto T, Kishimoto S, Omoto T, Watanabe H, Tokunaga T, Yukawa K, Kohno H, Mokuda S, Nojima T, Hirata S, Sugiyama E. Asymptomatic coronary aneurysms in a patient with eosinophilic granulomatosis with polyangiitis who developed a digital gangrene. Mod Rheumatol Case Rep 2020; 5:130-136. [PMID: 32791887 DOI: 10.1080/24725625.2020.1810404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A 33-year-old male with a history of bronchial asthma and allergic rhinitis was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA) eight years ago. The diagnosis was based on the presence of fever, remarkable eosinophilia, and painful digital ulcer. His signs and symptoms improved with a moderate dose of glucocorticoids. Thereafter, he was lost to follow-up, failing to attend any of the scheduled appointments. Three years later, he presented with painful digital gangrene on the lateral fold of the right ring fingernail and abdominal pain triggered by meals. Angiography showed multiple occlusions and severe stenoses of the peripheral arteries and coronary aneurysms, which confirmed the diagnosis of medium vessel vasculitis of the coronary and peripheral arteries due to flare up of EGPA. EGPA predominantly affects the small-sized vessels, but rarely the medium-sized vessels. Coronary vasculitis might occur asymptomatically, until the coronary stenosis becomes severe or myocardial infarction develops; hence, its prevalence is underestimated. In this case, a digital gangrene prompted us to perform a systemic angiography, leading to the diagnosis of coronary vasculitis. Careful observation for coronary lesions is necessary in patients with EGPA who develop digital gangrene.
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Affiliation(s)
- Mayu Sato
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yusuke Yoshida
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Tomohiro Sugimoto
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinji Kishimoto
- Department of Cardiovascular Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuji Omoto
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan.,Department of Rheumatology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Hirofumi Watanabe
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Tadahiro Tokunaga
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazutoshi Yukawa
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroki Kohno
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Sho Mokuda
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Takaki Nojima
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Eiji Sugiyama
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
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217
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Kataoka H, Tomita T, Kondo M, Mukai M. Presence of purpura is related to active inflammation in association with IL-5 in eosinophilic granulomatosis with polyangiitis. Rheumatol Int 2020; 41:449-454. [PMID: 32770271 PMCID: PMC7835155 DOI: 10.1007/s00296-020-04672-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/02/2020] [Indexed: 01/21/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a relatively rare necrotizing vasculitis that causes asthma, nasal involvement, peripheral nerve disturbance, renal disorder, and cutaneous lesions like purpura and is characterized by eosinophil infiltration into the damaged tissue. Purpura is the most common cutaneous lesion, but it remains unknown whether this skin lesion is associated with disease activity of EGPA and laboratory data including interleukin (IL)-5, a target cytokine of this disease. We conducted a search of our hospital electronic records for cases of EGPA from the last 10 years. Symptoms related to EGPA (fever, asthma, nasal and cutaneous manifestations, neuropathy), the Birmingham Vasculitis Activity Score (BVAS), and laboratory parameters, such as eosinophil count, urinalysis, antineutrophil cytoplasmic antibody (ANCA), CRP, IgE and IL-5, before and during treatment were compared among the eligible cases. A total of 28 EGPA patients (21 females and 7 males) were selected. Almost all developed peripheral neuropathy. Fever occurred in 25%, nasal symptoms in 38.1% and purpura in 44%. Glomerulonephritis developed in 7.7%. One patient had cardiac involvement (3.6%). The laboratory data showed a marked increase in peripheral eosinophil count, CRP, serum IgE and serum IL-5. ANCA was positive in 15.4%. In the univariate analysis, presence of purpura was associated with increased CRP and IL-5, and high BVAS score. Multivariate analysis revealed a robust relationship between purpura and CRP. Our findings showed that presence of purpura was associated with increased CRP and IL-5, and high disease activity in EGPA.
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Affiliation(s)
- Hiroshi Kataoka
- Department of Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, Japan.
| | - Tomoko Tomita
- Department of Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, Japan
| | - Makoto Kondo
- Department of Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, Japan
| | - Masaya Mukai
- Department of Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, Japan
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218
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Chang HC, Chou PC, Lai CY, Tsai HH. Antineutrophil Cytoplasmic Antibodies and Organ-Specific Manifestations in Eosinophilic Granulomatosis with Polyangiitis: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:445-452.e6. [PMID: 32771687 DOI: 10.1016/j.jaip.2020.07.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA), also known as Churg-Strauss syndrome, is a rare and often severe systemic vasculitis associated with antineutrophil cytoplasmic antibodies (ANCAs). EGPA can affect multiple organ systems, but the relationships between ANCA status and the organ-specific manifestations of EGPA in previous reports were inconsistent. OBJECTIVE To investigate the association of the ANCA status with organ-specific manifestations in EGPA. METHODS We performed a systematic review of studies published before March 16, 2020, in the PubMed, Embase, Web of Science, and Cochrane Library databases. The primary outcome was the association of ANCA status with organ-specific involvements of EGPA. Odds ratios (ORs) and 95% CIs were calculated using a random-effects model. RESULTS A total of 24 cross-sectional studies with 2527 patients with EGPA, including 921 ANCA-positive patients and 1606 ANCA-negative patients, were included in the meta-analysis. The significant results of pooled analyses revealed that compared with patients with EGPA with negative ANCA status, patients with EGPA with positive ANCA status had higher risks of peripheral neuropathy (OR, 1.701), renal involvement (OR, 5.097), and cutaneous purpura (OR, 1.746) and lower risks of pulmonary infiltrates (OR, 0.589) and cardiac involvement (OR, 0.427). The pooled analysis also revealed no significant association of ANCA status with asthma and involvements of the central nervous system, gastrointestinal tract, or skin. CONCLUSIONS This study provides more evidence that patients with EGPA may exhibit different features of disease based on their ANCA status.
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Affiliation(s)
- Hua-Ching Chang
- Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan; Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Pai-Chien Chou
- Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Division of Thoracic Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chun-Yu Lai
- Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hsiou-Hsin Tsai
- Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan; Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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219
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Neurologic Manifestations of Systemic Disease: Peripheral Nervous System. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00631-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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220
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Muradova E, Storonsky M, Ferenczi K, Santoro F. Eosinophilic granulomatosis with polyangiitis masquerading as hemorrhagic vesiculobullous herpes simplex infection. Int J Dermatol 2020; 59:e477-e480. [PMID: 32710554 DOI: 10.1111/ijd.15082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Elnara Muradova
- Department of Dermatology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Michael Storonsky
- Department of Dermatology, University of Connecticut Health Center, Farmington, CT, USA
| | - Katalin Ferenczi
- Department of Dermatology, University of Connecticut Health Center, Farmington, CT, USA
| | - Frank Santoro
- Department of Dermatology, University of Connecticut Health Center, Farmington, CT, USA.,Hartford Hospital, Hartford HealthCare Medical Group, Farmington, CT, USA
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221
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Afiari A, Gabriel A, Gaiki MR. Concurrent Use of Mepolizumab and Rituximab for Eosinophilic Granulomatosis With Polyangiitis and Multisystem Involvement. Cureus 2020; 12:e9242. [PMID: 32821588 PMCID: PMC7430662 DOI: 10.7759/cureus.9242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), formerly Churg-Strauss, is an anti-neutrophil cytoplasmic antibody (ANCA)-associated autoimmune vasculitis, involving small- and medium-sized arteries, which could involve several organs. This rare syndrome can present with a myriad of symptoms, which may make diagnosis challenging. It has been suggested that there are variants of EGPA, which may respond differently to available modes of treatment. Multiple and different mechanisms may be at play in each case of EGPA. This may influence the decision of clinicians to combine treatment strategies as done in this case. The addition of immunosuppressive agents other than high-dose steroids may mitigate end-organ damage, facilitate faster recovery, and prevent relapse. Rituximab among others has been seen to provide better outcomes, including a lower incidence of relapse. Mepolizumab was approved by the Food and Drug Administration (FDA) in 2017 for the treatment of EGPA. Administered at a higher dose than approved for severe eosinophilic asthma, it has been shown to lengthen remission in EGPA. The optimal dose and duration of therapy with mepolizumab remain unclear. The rarity alone of EGPA creates room for further investigation regarding pathogenesis, outcome over time, and treatment strategies, which may vary depending on how an individual case presents. This case describes the course of a 55-year-old woman who presented with respiratory symptoms, pauci-immune necrotizing granulomatous nephropathy, and neuropathy secondary to P-ANCA-positive EGPA who was successfully treated with rituximab and mepolizumab, in addition to glucocorticoids.
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Affiliation(s)
- Agura Afiari
- Internal Medicine, University of Connecticut (UCONN) School of Medicine, Hartford, USA
| | - Andre Gabriel
- Internal Medicine, University of Connecticut (UCONN) Health, Farmington, USA
| | - Meghana R Gaiki
- Nephrology, Saint Francis Hospital and Medical Center, Hartford, USA
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222
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Galant-Swafford J, Geng B, Leibel S, Akuthota P, Tucker S, Cernelc-Kohan M, Sheets R, Nation J, Jefferson AA. Two pediatric cases of ANCA-negative eosinophilic granulomatosis with polyangiitis successfully treated with dupilumab. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3643-3646.e1. [PMID: 32668296 DOI: 10.1016/j.jaip.2020.06.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/17/2020] [Accepted: 06/18/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Jessica Galant-Swafford
- Division of Rheumatology, Department of Medicine, Allergy & Immunology, University of California San Diego, San Diego, Calif.
| | - Bob Geng
- Division of Allergy, Immunology & Rheumatology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, Calif
| | - Sydney Leibel
- Division of Allergy, Immunology & Rheumatology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, Calif
| | - Praveen Akuthota
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California San Diego, San Diego, Calif
| | - Suzanne Tucker
- Division of Laboratory Services and Pathology, Rady Children's Hospital San Diego, San Diego, Calif
| | - Matejka Cernelc-Kohan
- Division of Pulmonary and Respiratory Medicine, Rady Children's Hospital San Diego, San Diego, Calif
| | - Robert Sheets
- Division of Allergy, Immunology & Rheumatology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, Calif
| | - Javan Nation
- Division of Otolaryngology, Rady Children's Hospital San Diego, San Diego, Calif
| | - Akilah A Jefferson
- Division of Allergy, Immunology & Rheumatology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, Calif
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223
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Guillevin L. Treatment of systemic necrotizing vasculitides: The 40-year experience of the French Vasculitis Study Group. Presse Med 2020; 49:104034. [PMID: 32650043 DOI: 10.1016/j.lpm.2020.104034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 05/19/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022] Open
Abstract
Treatment of vasculitides has benefited from the results of several prospective clinical trials focusing on the evaluation of new drugs, therapeutic strategies and adjuvant treatments. In the field of autoimmunity, vasculitides are the group of diseases for which the most important medical progress has been made, combining advances in understanding the pathogenetic mechanisms, classification of the various entities and willingness to evaluate treatments. Several international groups have been actively involved in these tasks. The French Vasculitis Study Group was the first to design and organize prospective trials in the field and to contribute to these medical advances. In this review, we analyze the different treatments and therapeutic strategies evaluated over the last few decades and, more precisely, the last 39 years by the French Vasculitis Study Group.
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Affiliation(s)
- Loïc Guillevin
- Department of Internal Medicine, Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, Paris, France.
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224
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Raffray L, Guillevin L. Updates for the treatment of EGPA. Presse Med 2020; 49:104036. [PMID: 32652104 DOI: 10.1016/j.lpm.2020.104036] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 05/19/2020] [Accepted: 07/02/2020] [Indexed: 12/17/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA, formerly Churg-Strauss syndrome) is the least frequent antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). Major advances of our knowledge on its pathophysiology have revealed features of both AAV and eosinophilic disorders. The development of targeted biotherapies for both diseases opened new possibilities for EGPA management. In this review, we highlight the rationale underlying the routine treatment strategy, which relies mainly on corticosteroids, with immunosuppressant adjunction for severe disease. However, novel therapies are still needed for refractory/relapsing disease and to alleviate the corticosteroid-dependence of asthma and chronic rhinosinusitis. At present, the most promising biotherapies target either eosinophil biology, like mepolizumab, an anti-interleukin-5, or the B-cell compartment, with rituximab. Recent clinical data on new treatment options are discussed and therapeutic strategies are proposed.
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Affiliation(s)
- Loïc Raffray
- Department of Internal Medicine, Félix-Guyon University Hospital of La Réunion, CS11021, Saint Denis, Reunion
| | - Loïc Guillevin
- Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Université Paris Descartes, 27, rue du Faubourg-Saint-Jacques, 75679 Paris Cedex 14, France.
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225
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Sacoto G, Boukhlal S, Specks U, Flores-Suárez LF, Cornec D. Lung involvement in ANCA-associated vasculitis. Presse Med 2020; 49:104039. [PMID: 32650042 DOI: 10.1016/j.lpm.2020.104039] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Lung involvement is one of the most common clinical features in ANCA-associated vasculitides (AAV), including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). In this review, we detail the five main presentations of pulmonary involvement in AAV: necrotizing granulomatous inflammation, tracheobronchial inflammation, pulmonary capillaritis, interstitial lung disease (ILD) and asthma with their clinical, radiological and therapeutic characteristics. The prevalence of these manifestations is variable according to the subtype of AAV, necrotizing granulomatous inflammation and tracheobronchial inflammation being defining features of GPA whereas ILD is primarily seen in patients with MPA, especially in association with ANCA directed against myeloperoxydase (MPO-ANCA), and asthma is characteristic of EGPA. Despite recent progresses in the diagnosis and management of these conditions, several questions remain and are discussed here, including local treatments for subglottic stenosis, the uncertain efficacy of plasma exchanges for alveolar hemorrhage, the potential role of antifibrotic agents in ILD associated with MPA, and the use of novel anti-IL-5 strategies in EGPA.
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Affiliation(s)
- Goethe Sacoto
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Calzada de Tlalpan 4502, Col. Sección XVI, CP 14080, Mexico City, Mexico
| | - Sara Boukhlal
- Inserm UMR1227, lymphocytes B et autoimmunité, service de rhumatologie, université de Bretagne Occidentale, CHU de Brest, Brest, France
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Luis Felipe Flores-Suárez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Calzada de Tlalpan 4502, Col. Sección XVI, CP 14080, Mexico City, Mexico
| | - Divi Cornec
- Inserm UMR1227, lymphocytes B et autoimmunité, service de rhumatologie, université de Bretagne Occidentale, CHU de Brest, Brest, France.
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226
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Zhang Z, Liu S, Guo L, Wang L, Wu Q, Zheng W, Hou Y, Tian X, Zeng X, Zhang F. Clinical Characteristics of Peripheral Neuropathy in Eosinophilic Granulomatosis with Polyangiitis: A Retrospective Single-Center Study in China. J Immunol Res 2020; 2020:3530768. [PMID: 32714994 PMCID: PMC7355369 DOI: 10.1155/2020/3530768] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 05/19/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To investigate clinical features, independent associated factors, treatment, and outcome of patients with peripheral neuropathy (PN) in eosinophilic granulomatosis with polyangiitis (EGPA). METHODS We retrospectively analyzed clinical data of 110 EGPA patients from 2007 to 2019 in Peking Union Medical College Hospital. The independent factors associated with PN in EGPA were analyzed with univariate and multivariate logistic regressions. RESULTS In EGPA with PN, paresthesia and muscle weakness were observed in 82% and 33% of patients, respectively. Both the upper and lower limbs were involved in 51% of patients. 30% of EGPA patients had symmetrical multiple peripheral neuropathy, whereas only 16.4% presented with mononeuritis multiplex. Compared to patients without PN, patients with PN had a higher erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, Birmingham vasculitis activity score (BVAS), and positivity of myeloperoxidase-antineutrophil cytoplasmic antibodies (MPO-ANCA). Regarding manifestations, patients with PN tended to develop weight loss and arthritis or joint pain. Notably, ANCA positivity, arthritis or joint pain, and higher BVAS were found to be independent associated factors for PN in EGPA. Patients with PN more frequently need glucocorticoid pulses and intravenous infusion of cyclophosphamide. With the longest follow-up of 11.0 years, we found that age and cardiac involvement were risk factors for survival, and female was the protective factor. CONCLUSION PN in EGPA frequently displays with symmetrical multiple peripheral neuropathy in China. Positive ANCA, arthritis or joint pain, and higher BVAS are the independent associated factors of PN in EGPA. Glucocorticoids with immunosuppressants are vital therapeutic strategy.
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Affiliation(s)
- Zhaocui 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
- Department of Rheumatology and Clinical Immunology, Gansu Province People's Hospital, Lanzhou, Gansu Province 730000, China
| | - 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 100730, China
| | - Ling Guo
- 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
- Department of Rheumatology, Dongying People's Hospital, Dongying, Shandong Province 257000, 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, Beijing 100730, China
| | - Qingjun Wu
- 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
| | - Wenjie Zheng
- 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
| | - Yong Hou
- 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
| | - Xinping Tian
- 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
| | - 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 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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Ishaq U, Malik J, Baig A, Javaid M, Ikram U. Eosinophilic Granulomatosis With Polyangiitis (Churg-Strauss Syndrome) Mimicking a Stroke and Acute Coronary Syndrome: A Case Report. Cureus 2020; 12:e8984. [PMID: 32775066 PMCID: PMC7402424 DOI: 10.7759/cureus.8984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Churg-Strauss syndrome (CSS) is a rare disease of multiple organ involvement attributed to asthma, eosinophilia, and vasculitis as a diagnostic criterion. Here we report a case of CSS presenting with left leg weakness and chest pain with a diagnosis of myocarditis and neuropathy. Eosinophilia, history of asthma, peripheral neurological damage led to the diagnosis of CSS. Transthoracic echo showed a full-sized segmental wall motion abnormality with normal CT angiography. He responded well to steroid therapy.
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Affiliation(s)
- Uzma Ishaq
- Hematology and Medical Oncology, Fauji Foundation Hospital, Rawalpindi, PAK
| | - Jahanzeb Malik
- Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK
| | - Adnan Baig
- Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK
| | - Muhammad Javaid
- Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK
| | - Umar Ikram
- Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK
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228
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Löffler C, Mahrhold J, Fogarassy P, Beyer M, Hellmich B. Two Immunocompromised Patients With Diffuse Alveolar Hemorrhage as a Complication of Severe Coronavirus Disease 2019. Chest 2020; 158:e215-e219. [PMID: 32622819 PMCID: PMC7331533 DOI: 10.1016/j.chest.2020.06.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 06/08/2020] [Accepted: 06/10/2020] [Indexed: 01/22/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a severe and potentially life-threatening disease manifestation. In addition to autoimmune diseases such as antineutrophil cytoplasmic antibody-associated vasculitis and anti-glomerular basement membrane syndrome, pulmonary viral infections are known to be culprits of DAH. Health-care providers worldwide in the coronavirus disease 2019 pandemic have been confronted with an unprecedented number of viral lung infections, with great variance in symptoms and severity. Hemoptysis, the key symptom of DAH, is a rare complication. We present two cases of immunocompromised patients with rapidly developing hypoxemic respiratory failure and evidence of DAH in the context of severe acute respiratory syndrome coronavirus 2 infection.
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Affiliation(s)
- Christian Löffler
- Department of Internal Medicine, Rheumatology and Immunology, medius Klinik Kirchheim, Academic Teaching Hospital University of Tübingen, Kirchheim unter Teck, Germany.
| | - Juliane Mahrhold
- Department of Internal Medicine, Rheumatology and Immunology, medius Klinik Kirchheim, Academic Teaching Hospital University of Tübingen, Kirchheim unter Teck, Germany
| | - Peter Fogarassy
- Department of Internal Medicine, Cardiology and Intensive Care Medicine, medius Klinik Kirchheim, Academic Teaching Hospital University of Tübingen, Kirchheim unter Teck, Germany
| | - Martin Beyer
- Department of Internal Medicine, Cardiology and Intensive Care Medicine, medius Klinik Kirchheim, Academic Teaching Hospital University of Tübingen, Kirchheim unter Teck, Germany
| | - Bernhard Hellmich
- Department of Internal Medicine, Rheumatology and Immunology, medius Klinik Kirchheim, Academic Teaching Hospital University of Tübingen, Kirchheim unter Teck, Germany
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229
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Morita TCAB, Criado PR, Criado RFJ, Trés GFS, Sotto MN. Update on vasculitis: overview and relevant dermatological aspects for the clinical and histopathological diagnosis - Part II. An Bras Dermatol 2020; 95:493-507. [PMID: 32527591 PMCID: PMC7335877 DOI: 10.1016/j.abd.2020.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 04/28/2020] [Indexed: 12/26/2022] Open
Abstract
Vasculitis is a group of several clinical conditions in which the main histopathological finding is fibrinoid necrosis in the walls of blood vessels. This article assesses the main dermatological aspects relevant to the clinical and laboratory diagnosis of small- and medium-vessel cutaneous and systemic vasculitis syndromes. The most important aspects of treatment are also discussed.
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Affiliation(s)
| | | | | | - Gabriela Franco S Trés
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Mirian Nacagami Sotto
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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230
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Moiseev S, Bossuyt X, Arimura Y, Blockmans D, Csernok E, Damoiseaux J, Emmi G, Flores-Suárez LF, Hellmich B, Jayne D, Jennette JC, Little MA, Mohammad AJ, Moosig F, Novikov P, Pagnoux C, Radice A, Sada KE, Segelmark M, Shoenfeld Y, Sinico RA, Specks U, Terrier B, Tzioufas AG, Vaglio A, Zhao MH, Cohen Tervaert JW. International Consensus on ANCA Testing in Eosinophilic Granulomatosis with Polyangiitis. Am J Respir Crit Care Med 2020; 202:1360-1372. [PMID: 32584187 DOI: 10.1164/rccm.202005-1628so] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022] Open
Abstract
An international consensus on anti-neutrophil cytoplasm antibodies (ANCA) testing in eosinophilic granulomatosis with polyangiitis (EGPA) is presented. ANCA, specific for myeloperoxidase (MPO), can be detected in 30-35% of EGPA patients. MPO-ANCA should be tested with antigen-specific immunoassays in any patient with eosinophilic asthma and clinical features suggesting EGPA, including constitutional symptoms, purpura, polyneuropathy, unexplained heart, gastrointestinal or kidney disease, and/or pulmonary infiltrates or hemorrhage. A positive MPO-ANCA result contributes to the diagnostic work‑up for EGPA. Patients with MPO-ANCA associated EGPA have more frequently vasculitis features, such as glomerulonephritis, neuropathy, and skin manifestations than patients with ANCA negative EGPA. However, the presence of MPO-ANCA is neither sensitive nor specific enough to identify whether a patient should be subclassified as having "vasculitic" or "eosinophilic" EGPA. At present, ANCA status cannot guide treatment decisions, that is, whether cyclophosphamide, rituximab or mepolizumab should be added to conventional glucocorticoid treatment. In EGPA, monitoring of ANCA is only useful when MPO-ANCA was tested positive at disease onset.
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Affiliation(s)
- Sergey Moiseev
- Sechenov First Moscow State Medical University, Tareev Clinic of Internal Diseases, Moscow, Russian Federation;
| | - Xavier Bossuyt
- KU Leuven University Hospitals Leuven, 60182, Leuven, Belgium
| | | | | | | | - Jan Damoiseaux
- Maastricht University Medical Centre+, 199236, Maastricht, Netherlands
| | - Giacomo Emmi
- University of Florence, 9300, Department of Experimental and Clinical Medicine, Firenze, Italy
| | | | - Bernhard Hellmich
- Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim-unter-Teck, Germany
| | - David Jayne
- University of Cambridge, 2152, Cambridge, United Kingdom of Great Britain and Northern Ireland
| | - J Charles Jennette
- University of North Carolina at Chapel Hill, 2331, Chapel Hill, North Carolina, United States
| | - Mark A Little
- Trinity Translational Medicine Institute, Dublin, Ireland
| | | | | | - Pavel Novikov
- Sechenov First Moscow State Medical University, Tareev Clinic of Internal Diseases, Moscow, Russian Federation
| | | | | | - Ken-Ei Sada
- Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, 199491, Okayama, Japan
| | | | | | - Renato A Sinico
- Università degli Studi di Milano-Bicocca, 9305, Milano, Italy
| | | | | | | | | | - Ming-Hui Zhao
- Peking University First Hospital, 26447, Beijing, China
| | - Jan Willem Cohen Tervaert
- University of Alberta, Medicine, Edmonton, Alberta, Canada
- Maastricht University, MHeNS, Maastricht, Netherlands
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231
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Solans-Laqué R, Rodriguez-Carballeira M, Rios-Blanco JJ, Fraile G, Sáez-Comet L, Martinez-Zapico A, Frutos B, Solanich X, Fonseca-Aizpuru E, Pasquau-Liaño F, Zamora M, Oristrell J, Fanlo P, Lopez-Dupla M, Abdilla M, García-Sánchez I, Sopeña B, Castillo MJ, Perales I, Callejas JL. Comparison of the Birmingham Vasculitis Activity Score and the Five-Factor Score to Assess Survival in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Study of 550 Patients From Spain (REVAS Registry). Arthritis Care Res (Hoboken) 2020; 72:1001-1010. [PMID: 31033198 DOI: 10.1002/acr.23912] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 04/23/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To compare the accuracy of the Birmingham Vasculitis Activity Score (BVAS), version 3, and the Five Factor Score (FFS), version 1996 and version 2009, to assess survival in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). METHODS A total of 550 patients with AAV (41.1% with granulomatosis with polyangiitis, 37.3% with microscopic polyangiitis, and 21.6% with eosinophilic granulomatosis with polyangiitis), diagnosed between 1990 and 2016, were analyzed. Receiver operating characteristic (ROC) curves and multivariable Cox analysis were used to assess the relationships between the outcome and the different scores. RESULTS Overall mortality was 33.1%. The mean ± SD BVAS at diagnosis was 17.96 ± 7.82 and was significantly higher in nonsurvivors than in survivors (mean ± SD 20.0 ± 8.14 versus 16.95 ± 7.47, respectively; P < 0.001). The mean ± SD 1996 FFS and 2009 FFS were 0.81 ± 0.94 and 1.47 ± 1.16, respectively, and were significantly higher in nonsurvivors than in survivors (mean ± SD 1996 FFS 1.17 ± 1.07 versus 0.63 ± 0.81 [P < 0.001] and 2009 FFS 2.13 ± 1.09 versus 1.15 ± 1.05 [P < 0.001], respectively). Mortality rates increased according to the different 1996 FFS and 2009 FFS categories. In multivariate analysis, BVAS, 1996 FFS, and 2009 FFS were significantly related to death (P = 0.007, P = 0.020, P < 0.001, respectively), but the stronger predictor was the 2009 FFS (hazard ratio 2.9 [95% confidence interval 2.4-3.6]). When the accuracy of BVAS, 1996 FFS, and 2009 FFS to predict survival was compared in the global cohort, ROC analysis yielded area under the curve values of 0.60, 0.65, and 0.74, respectively, indicating that 2009 FFS had the best performance. Similar results were obtained when comparing these scores in patients diagnosed before and after 2001 and when assessing the 1-year, 5-year, and long-term mortality. Correlation among BVAS and 1996 FFS was modest (r = 0.49; P < 0.001) but higher than between BVAS and the 2009 FFS (r = 0.28; P < 0.001). CONCLUSION BVAS and FFS are useful to predict survival in AAV, but the 2009 FFS has the best prognostic accuracy at any point of the disease course.
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232
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Padoan R, Chieco Bianchi F, Marchi MR, Cazzador D, Felicetti M, Emanuelli E, Vianello A, Nicolai P, Doria A, Schiavon F. Benralizumab as a glucocorticoid-sparing treatment option for severe asthma in eosinophilic granulomatosis with polyangiitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3225-3227.e2. [PMID: 32505716 DOI: 10.1016/j.jaip.2020.05.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Roberto Padoan
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Fulvia Chieco Bianchi
- Respiratory Pathophysiology Division, Department of Cardio-Thoracic-Vascular Sciences, University of Padova, Padova, Italy
| | - Maria Rita Marchi
- Respiratory Pathophysiology Division, Department of Cardio-Thoracic-Vascular Sciences, University of Padova, Padova, Italy
| | - Diego Cazzador
- Otorhinolaryngology Unit, Department of Neurosciences, University of Padova, Padova, Italy; Section of Human Anatomy, Department of Neurosciences, University of Padova, Padova, Italy
| | - Mara Felicetti
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Enzo Emanuelli
- Otorhinolaryngology Unit, Department of Neurosciences, University of Padova, Padova, Italy
| | - Andrea Vianello
- Respiratory Pathophysiology Division, Department of Cardio-Thoracic-Vascular Sciences, University of Padova, Padova, Italy
| | - Piero Nicolai
- Otorhinolaryngology Unit, Department of Neurosciences, University of Padova, Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Franco Schiavon
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy.
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233
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Retinal artery occlusion followed by contralateral amaurosis fugax in association with eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Am J Ophthalmol Case Rep 2020; 18:100683. [PMID: 32309675 PMCID: PMC7154996 DOI: 10.1016/j.ajoc.2020.100683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/20/2020] [Accepted: 03/27/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To describe two cases of retinal artery occlusion followed by contralateral amaurosis fugax associated with eosinophilic granulomatosis with polyangiitis (EGPA, formerly known as Churg-Strauss syndrome). Observations Case 1 is a 57 year-old male who presented with transient vision loss in the right eye two weeks after a cilioretinal artery occlusion in the left eye. Evaluation eventually led to a diagnosis of EGPA. The patient was treated with high-dose steroids followed by systemic immunomodulatory therapy. Vision in the right eye recovered to 20/20 with no further episodes of vision loss. Case 2 is a 55 year-old male with a known diagnosis of EGPA who presented with transient vision loss in the right eye four weeks after a central retinal artery occlusion of the left eye. This patient also successfully recovered vision in the right eye after treatment with high-dose steroids following a change in his systemic immunomodulatory therapy. Conclusions and Importance While ANCA-vasculitides are an uncommon cause of retinal artery occlusion and amaurosis fugax, it is important that they remain in the differential diagnosis, as good visual outcomes can be achieved with prompt initiation of appropriate therapies.
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234
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Randomized clinical trials in ANCA-associated vasculitis: a systematic analysis of the WHO - International Clinical Trials Registry Platform. Orphanet J Rare Dis 2020; 15:130. [PMID: 32471463 PMCID: PMC7257545 DOI: 10.1186/s13023-020-01408-6] [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: 04/01/2020] [Accepted: 05/14/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The analysis of the main features of randomized controlled trials (RCTs) on ANCA-associated vasculitis (AAV) can inform future study design. METHODS We searched within the International Clinical Trials Registry Platform all registered RCTs on AAV from October 2008 to December 2018. Two reviewers selected studies according to pre-specified eligibility criteria. We retrieved information including countries, funding, design, sample sizes, eligibility criteria, primary outcomes (POs), and treatments. RESULTS Among the 40 RCTs identified, 22 (55%) were conducted in Europe, 29 (72,5%) in a single country, 14 (35%) were industry-funded. The median number of patients planned to enrol was 68 (IQR 36-138). Only 28% of RCTs targeted a single vasculitis, and ANCA negative patients were not included in about 40% of studies. Interventions investigated were mainly drugs given to induce (40%) or maintain (32.5%) remission. Eighty-five percent of POs were considered being 'patient-important', but discrepancies in definition of disease states, such as remission or relapse were observed. Glucocorticoids use was part of the PO in < 25% of studies. The number of trials targeting a single disease, non-industry funded, incorporating glucocorticoids in PO, as well as the planned sample size increased over time. CONCLUSION Despite the important achievements in the field, a better harmonization of eligibility, and outcome criteria across studies is an important objective to pursue in next future.
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235
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Moller D, Tan J, Gauiran DTV, Medvedev N, Hudoba M, Carruthers MN, Dehghan N, Berghe J, Bruyère H, Chen LY. Causes of hypereosinophilia in 100 consecutive patients. Eur J Haematol 2020; 105:292-301. [DOI: 10.1111/ejh.13437] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Daniel Moller
- Department of Medicine University of British Columbia Vancouver BC Canada
| | - Julia Tan
- Department of Medicine University of British Columbia Vancouver BC Canada
| | | | - Nadia Medvedev
- Division of Hematopathology University of British Columbia Vancouver BC Canada
| | - Monika Hudoba
- Division of Hematopathology University of British Columbia Vancouver BC Canada
| | | | - Natasha Dehghan
- Division of Rheumatology University of British Columbia Vancouver BC Canada
| | - Janette Berghe
- Department of Pathology and Laboratory Medicine University of British Columbia and Cytogenomics LaboratoryVancouver General Hospital Vancouver BC Canada
| | - Helene Bruyère
- Department of Pathology and Laboratory Medicine University of British Columbia and Cytogenomics LaboratoryVancouver General 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
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Differentiation Between Eosinophilic Otitis Media and Otitis Media Associated With Eosinophilic Granulomatosis With Polyangiitis. Otol Neurotol 2020; 40:e796-e802. [PMID: 31290803 DOI: 10.1097/mao.0000000000002295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To perform comparisons and clarify differences in clinical manifestations between eosinophilic otitis media (EOM) and otitis media associated with eosinophilic granulomatosis with polyangiitis (EGPA). STUDY DESIGN Retrospective case review. SETTING Tertiary referral center. PATIENTS Twenty-two ears of 11 patients exhibiting EOM (EOM group) and 20 ears of 12 patients exhibiting otitis media associated with EGPA (EGPA group). MAIN OUTCOME MEASURES Otological manifestations, nasal and paranasal manifestations, incidence of asthma, positivity for serum antineutrophil cytoplasmic antibodies (ANCA), total serum immunoglobulin (Ig) E level, peripheral blood eosinophil fraction, and hearing outcomes. RESULTS The incidence and age of onset of asthma and chronic rhinosinusitis were comparable between the EOM and EGPA groups. Moreover, otological findings and hearing outcomes at the initial visit were similar in both groups. Computed tomography images of the paranasal sinus showed predominant opacification of the ethmoid sinus in both groups. Although the total serum IgE level was not significantly different, the peripheral blood eosinophil fraction was significantly larger in the EGPA group than in the EOM group (p = 0.0035). Furthermore, the rate of myeloperoxidase-antineutrophil cytoplasmic antibodies (ANCA) positivity was significantly higher in the EGPA group than in the EOM group (p = 0.019). CONCLUSIONS The findings of the present study suggest that the phenotypic characteristics of EOM closely resemble those of otitis media associated with EGPA in early stages before the appearance of vasculitis. Therefore, it is challenging to differentiate the two conditions purely on the basis of otorhinological examinations.
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Abstract
INTRODUCTION Rituximab, an anti-B-cell biological therapy, has been investigated in several clinical trials on antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs). AREAS COVERED In this paper, the clinical trials and open-label studies on rituximab efficacy and safety in treating AAVs are reviewed. EXPERT OPINION Rituximab achieved high remission-induction and sustained-maintenance rates for patients with these severe diseases, thereby challenging the cornerstone treatment of corticosteroids and cyclophosphamide followed by azathioprine. Rituximab should be used as first-line therapy with corticosteroids to induce remission of severe AAVs, especially in situations in which cyclophosphamide may be problematic (relapse after cyclophosphamide, women of childbearing age, risk of malignancy). Cyclophosphamide indications are likely to be restricted in the future. Whenever possible, rituximab should be preferred to azathioprine to maintain remission. The current maintenance regimen has been extended to at least 18 months but its optimal duration remains unknown and recent data suggest the possibility to extend treatment to 4 years. Future challenges include defining the best dose regimen: at present, different schedules are used as alternatives to those recognized as standards by health authorities. In addition, it remains to identify which patients will benefit the most from long-term retreatment: potentially those with relapsing disease or anti-proteinase-3 ANCA-positivity.
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Affiliation(s)
- Loïc Raffray
- Department of Internal Medicine, Félix-Guyon University Hospital of La Réunion , Saint-Denis, France
| | - Loïc Guillevin
- Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Université Paris Descartes , Paris, France
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238
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Puéchal X, Pagnoux C, Baron G, Lifermann F, Geffray L, Quémeneur T, Saraux JL, Wislez M, Cottin V, Ruivard M, Limal N, Aouba A, Bonnotte B, Néel A, Agard C, Cohen P, Terrier B, Le Jeunne C, Mouthon L, Ravaud P, Guillevin L. Non-severe eosinophilic granulomatosis with polyangiitis: long-term outcomes after remission-induction trial. Rheumatology (Oxford) 2020; 58:2107-2116. [PMID: 31056661 DOI: 10.1093/rheumatology/kez139] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/16/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE In a previous controlled trial, 1-year adjunction of AZA to glucocorticoids (GC) for patients with non-severe, newly diagnosed eosinophilic granulomatosis with polyangiitis (EGPA) failed to lower remission failure, vasculitis relapse and isolated asthma/rhinosinus exacerbation rates, or cumulative GC use at month (M) 24. The aim of this study was to analyse longer-term outcomes to determine whether subsequent vasculitis relapse or isolated asthma/rhinosinus exacerbation (IARE) rates differed. METHODS After M24, patients were followed prospectively, being treated based on physicians' best judgment. Flares and reasons for increased GC dose or immunosuppressant use were recorded, and reviewed according to randomization group to distinguish vasculitis relapses from IAREs according to EGPA Task Force recommendations. RESULTS Fifty EGPA trial participants were followed for a median (interquartile range) of 6.3 (5.4-7.6) years; two (4%) died 11 months post-inclusion. By M24, vasculitis had relapsed in 21/49 (43%) patients and 14/50 (28%) had IAREs. Another patient died 4.8 years post-inclusion (infection). Among nine patients with subsequent vasculitis relapses, three had a major relapse and three had their first relapse after M24; among 25 patients with later IAREs, 17 occurred after M24. At 5 years, respective vasculitis relapse and IARE rates were 48% (95% CI 34.0, 62.6) and 56% (95% CI 41.7, 70.8), with no between-arm differences (P = 0.32 and 0.13). No entry clinical or biological parameter was associated with these outcomes during follow-up. CONCLUSION These results confirmed that 1-year AZA and GC induction obtained good overall survival but no long-term benefit for non-severe EGPA patients. Vasculitis relapses, occurring mostly during the first 2 years, and IAREs, occurring throughout follow-up, require other preventive treatments. TRIAL REGISTRATION ClinicalTrials.gov, https://clinicaltrials.gov, NCT00647166.
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Affiliation(s)
- Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, APHP, Université Paris Descartes, Paris, France
| | - Christian Pagnoux
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, APHP, Université Paris Descartes, Paris, France.,Vasculitis Clinic, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Gabriel Baron
- Université Paris Descartes, Hôtel-Dieu, APHP, Paris, France
| | | | | | | | | | - Marie Wislez
- Hôpital Tenon, APHP, Université Pierre et Marie Curie, Paris, France
| | - Vincent Cottin
- Hôpital Louis-Pradel, Lyon and UMR754, Université Claude Bernard Lyon 1, Lyon, France
| | - Marc Ruivard
- Centre Hospitalier Universitaire Estaing, Clermont-Ferrand, France
| | - Nicolas Limal
- Hôpital Henri-Mondor, Université Paris-Est Créteil, APHP, Créteil, France
| | - Achille Aouba
- Centre Hospitalier Universitaire Côte de Nacre, Caen, France
| | | | - Antoine Néel
- Centre Hospitalier Universitaire Hôtel-Dieu, Nantes, France
| | | | - Pascal Cohen
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, APHP, Université Paris Descartes, Paris, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, APHP, Université Paris Descartes, Paris, France
| | - Claire Le Jeunne
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, APHP, Université Paris Descartes, Paris, France
| | - Luc Mouthon
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, APHP, Université Paris Descartes, Paris, France
| | | | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, APHP, Université Paris Descartes, Paris, France
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239
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Microscopic Polyangiitis Initially Presumed to Be Endocarditis. Case Rep Dent 2020; 2020:7020595. [PMID: 32257454 PMCID: PMC7102490 DOI: 10.1155/2020/7020595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/05/2020] [Indexed: 11/28/2022] Open
Abstract
The antineutrophil cytoplasmic antibody- (ANCA-) associated vasculitides (AAVs), which include fever of unknown origin (FUO), are rare diseases characterized by necrotizing inflammation of small blood vessels and the presence of ANCAs. Microscopic polyangiitis (MPA) is a subtype of the AAVs. Although the prevalence of AAVs has generally increased over the last 20 years, there have been rare reports from the dental and oral surgery field. In this article, we present a case of MPA suspected to be infective endocarditis (IE) following tooth extraction.
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240
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Koppikar S, Al-Dabie G, Jerome D, Vinik O. Eosinophilic granulomatosis with polyangiitis presenting with myositis: case based review. Rheumatol Int 2020; 40:1163-1170. [PMID: 32270295 DOI: 10.1007/s00296-020-04567-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Abstract
Eosinophilic granulomatosis with polyangitis (EGPA) is a systemic necrotizing small-vessel vasculitis that presents heterogeneously as a multi-organ disease. EGPA evolves through three phases: (1) prodromic phase with asthma, atopy and sinusitis, (2) eosinophilic phase characterized by peripheral eosinophilia and eosinophilic infiltration without necrosis, and (3) vasculitic phase involving organ damage. EGPA often presents with asthma, mononeuritis multiplex, lung infiltrates, sinusitis and constitutional symptoms. Although myalgias are common, EGPA rarely presents with true weakness with elevated creatinine kinase (CK). We describe a rare case of a patient presenting with eosinophilic myositis, who subsequently developed fulminant EGPA. The patient's diagnosis was supported by an initial clinical presentation of weakness and elevated CK, followed by fleeting pulmonary infiltrates and mononeuritis multiplex, peripheral eosinophilia, and strongly positive myeloperoxidase anti-cytoplasmic antibody (MPO-ANCA). Muscle biopsy revealed eosinophilic myositis. The patient responded well to high-dose glucocorticoids and cyclophosphamide with improved symptoms and biochemical markers. Based on our literature review, there are only seven similar cases reported of EGPA presenting with myositis and confirmatory muscle biopsies. There is significant heterogeneity in their clinical findings, histopathology and treatments that were used. Our case report and literature review highlights the importance of recognizing myositis as an initial presenting symptom of EGPA, providing an opportunity for early diagnosis and treatment to reduce risk of further disease progression and morbidity.
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Affiliation(s)
- Sahil Koppikar
- Division of Rheumatology, University of Toronto, Toronto, ON, Canada. .,Division of Rheumatology, Women's College Hospital, University of Toronto, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
| | - Ghaydaa Al-Dabie
- Division of Rheumatology, University of Toronto, Toronto, ON, Canada
| | - Dana Jerome
- Division of Rheumatology, University of Toronto, Toronto, ON, Canada.,Division of Rheumatology, Women's College Hospital, University of Toronto, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Ophir Vinik
- Division of Rheumatology, University of Toronto, Toronto, ON, Canada.,Division of Rheumatology, St. Michael's Hospital, Toronto, ON, Canada
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241
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Abstract
Vasculitis is characterized by inflammation of the vascular wall. It reaches vessels of different sizes and locations, conditioning multisystem and complex manifestations that require a holistic approach. Antineutrophil cytoplasmic antibody-associated vasculitis has an annual incidence rate of 20 per million inhabitants. It is the result of the interaction of infectious, genetic and environmental factors and manifest itself with varied and unspecific symptoms, often reaching the general state, respiratory and renal systems. The combination of clinical, laboratory, imaging and fundamentally histological changes allows the diagnosis and classification of the extent / severity of the disease necessary for the decision of the therapeutics to be taken. Glucocorticoids are generally used; with methotrexate being considered when localized disease and cyclophosphamide, rituximab or azathioprine when generalized disease. A systematized approach can increase survival rates from 12% to 70% over a 5-year span.
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Affiliation(s)
- Fernando Salvador
- Autoimmune Diseases Unit, Internal Medicine Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Avenida da Noruega, 5000-508 Vila Real, Portugal; NEDAI/SPMI Autoimmune Diseases Group/Portuguese Society of Internal Medicine, Portugal.
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242
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Update on the Management of Respiratory Manifestations of the Antineutrophil Cytoplasmic Antibodies-Associated Vasculitides. Clin Chest Med 2020; 40:573-582. [PMID: 31376892 DOI: 10.1016/j.ccm.2019.05.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Antibody-associated vasculitis comprises 3 small vessel vasculitis syndromes: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic polyangiitis (EGPA). This article outlines the major tracheobronchial and pulmonary parenchymal disease manifestations of GPA and MPA and their management, as well as relevant recent advances in the treatment of EGPA. Shared trends in the management of all 3 syndromes are: (1) a focus on glucocorticoid avoidance and (2) an increasing reliance on biologic agents. Evidence from randomized controlled trials and large cohort studies in support of these trends as well as ongoing research efforts are summarized.
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243
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Nishi R, Koike H, Ohyama K, Fukami Y, Ikeda S, Kawagashira Y, Iijima M, Katsuno M, Sobue G. Differential clinicopathologic features of EGPA-associated neuropathy with and without ANCA. Neurology 2020; 94:e1726-e1737. [PMID: 32217776 DOI: 10.1212/wnl.0000000000009309] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 11/01/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To investigate the clinicopathologic features of eosinophilic granulomatosis with polyangiitis (EGPA)-associated neuropathy with a focus on the presence or absence of anti-neutrophil cytoplasmic antibodies (ANCAs). METHODS We examined the clinical features and pathologic findings of sural nerve biopsy specimens from 82 patients with EGPA-associated neuropathy. Of these patients, 32.9% were myeloperoxidase (MPO)-ANCA positive, and 67.1% were MPO-ANCA negative. PR3-ANCA was negative in all of 78 examined patients. RESULTS Upper limb symptoms were more frequently reported as initial neuropathic manifestations in the MPO-ANCA-positive group than in the MPO-ANCA-negative group (44.4% vs 14.6%, p < 0.01). The serum levels of C-reactive protein were significantly higher in the MPO-ANCA-positive group than in the MPO-ANCA-negative group (p < 0.05). Sural nerve biopsy specimens showed findings suggestive of vasculitis (i.e., destruction of vascular structures) in epineurial vessels; these results were seen more frequently in the MPO-ANCA-positive group than in the MPO-ANCA-negative group (p < 0.0001). Conversely, the numbers of eosinophils in the lumen of the epineurial vessels (p < 0.01) and epineurial vessels occluded by intraluminal eosinophils (p < 0.05) were higher in the MPO-ANCA-negative group than in the MPO-ANCA-positive group. Furthermore, the incidence of eosinophil infiltration in the endoneurium was higher in the MPO-ANCA-negative group than in the MPO-ANCA-positive group (p < 0.01). CONCLUSIONS This study suggests that the pathogenesis of EGPA comprises at least 2 distinct mechanisms: ANCA-associated vasculitis resulting in ischemic effects and inflammation, which is prominent in MPO-ANCA-positive patients, and eosinophil-associated vascular occlusion leading to ischemia and eosinophil-associated tissue damage, which is conspicuous in MPO-ANCA-negative patients.
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Affiliation(s)
- Ryoji Nishi
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Haruki Koike
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan.
| | - Ken Ohyama
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Yuki Fukami
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Shohei Ikeda
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Yuichi Kawagashira
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Masahiro Iijima
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Masahisa Katsuno
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Gen Sobue
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan.
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244
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Coates ML, Martinez Del Pero M. Updates in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis for the ENT surgeon. Clin Otolaryngol 2020; 45:316-326. [PMID: 32145151 DOI: 10.1111/coa.13524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/13/2020] [Accepted: 02/29/2020] [Indexed: 12/31/2022]
Abstract
ENT involvement is common in ANCA-associated vasculitis (AAV), particularly in GPA and EGPA. Early recognition and treatment is important for good outcomes, yet evidence suggests that UK ENT surgeons may not consistently recognise the early features of AAV, despite a similar incidence to vestibular schwannoma. AAV is a rapidly advancing field, with significant developments in the understanding of its pathogenesis, classification and treatment over the past decade. Relevant vasculitis mimics are also discussed with a particular focus on the increasing prevalence of vasculitis mimics driven by an increase in recreational cocaine use, as well as the emergence and reclassification of several other vasculitis mimics in the head and neck. This article reviews key recent updates in the vasculitis literature, with a particular focus on those relevant to recognition and diagnosis of AAV for the ENT surgeon. Strengths and limitations of relevant diagnostic testing are discussed, and a method of evaluation of patients with features of AAV presenting to ENT services is outlined.
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245
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A Case of Cutaneous Arteritis Presenting as Infiltrated Erythema in Eosinophilic Granulomatosis With Polyangiitis: Features of the Unique Morphological Evolution of Arteritis as a Diagnostic Clue. Am J Dermatopathol 2020; 41:832-834. [PMID: 31634169 DOI: 10.1097/dad.0000000000001451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA, formerly Churg-Strauss syndrome) is a rare systemic vasculitis affecting small- and medium-sized vasculature, associated with asthma and eosinophilia. Different levels of vasculitis in cutaneous lesions have been observed, including dermal small vessel vasculitis and subcutaneous muscular vessel vasculitis. Although the EGPA-associated small vessel vasculitis described as leukocytoclastic vasculitis can be often found in the documented literature, the features of subcutaneous muscular vessel vasculitis in EGPA-associated cutaneous lesions have been rarely demonstrated clinically and histopathologically in English literature. Herein, we report a case of EGPA involving infiltrated erythema on the extremities, with different stages of cutaneous arteritis characterized by eosinophilic arteritis and granulomatous arteritis in the same affected artery. We present this as a unique diagnostic clue for EGPA.
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246
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Treatment and its side effects in ANCA-associated vasculitides - Study based on POLVAS registry data. Adv Med Sci 2020; 65:156-162. [PMID: 31958704 DOI: 10.1016/j.advms.2020.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 09/08/2019] [Accepted: 01/03/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE The aim of this study is to present the treatment modalities and associated side effects in a Polish nation-wide ANCA-associated vasculitides (AAV) patients' cohort. MATERIALS AND METHODS Retrospective analysis of patients diagnosed with AAV between 1990 and 2016, included in the POLVAS registry was performed. Standard descriptive statistic methods were used with an emphasis on the treatment modalities. RESULTS There were 625 patients diagnosed with AAV included in this study: 417 cases of granulomatosis with polyangiitis (GPA; 66.7%), 106 cases of microscopic polyangiitis (MPA; 17.0%) and 102 cases of eosinophilic granulomatosis with polyangiitis (EGPA; 16.3%). The mean age at the date of diagnosis was 50.4 (±15.7) years and the median observational period amounted to 4.0 (2.0-8.0) years. Glucocorticosteroids (GCs) were the medicaments most frequently used for remission induction (593/622; 95.3%), followed by cyclophosphamide (487/622; 78.3%), rituximab (44/622; 7.1%), and methotrexate (39/622; 6.3%). GCs were also most frequently administered for maintenance therapy (499/592; 84.3%), followed by azathioprine (224/592; 37.8%), methotrexate (136/592; 23.0%) and mycophenolate mofetil (99/592; 16.7%). The median cumulative doses of cyclophosphamide and rituximab equalled 7.99 g (4.18-14.0) and 2000 mg (1500-2800), respectively. The most commonly observed adverse events included: infections - 214/551 cases (38.8%), which were associated with the time of observation (OR = 1.05; 95% CI 1.01-1.10), the use of GCs intravenous pulses (OR = 2.76; 95% CI 1.68-4.54) and need for haemodialysis (OR = 1.73; 95% CI 1.10-2.71). CONCLUSIONS Polish patients with AAV were predominantly treated according to appropriate guidelines. The most frequent adverse events were typical for usually administered immunosuppressive treatment.
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247
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Abstract
Vasculitis, characterized by inflammation and necrosis, manifests a wide spectrum of presentation by involving a vasculature of various sizes and locations. A definitive diagnosis of vasculitis invariably requires histologic confirmation since there are no diagnostic clinical, imaging, or laboratory findings. The most widely adopted vasculitis classification is the Chapel Hill Consensus Conference (CHCC) nomenclature of systemic vasculitis which integrated clinical symptoms, histopathologic features, and laboratory findings. This classification accounts for the size of the involved vessels. This chapter outlines the clinical and histologic features of the small-vessel vasculitis including the immune complex vasculitis and antineutrophil cytoplasmic antibody-associated vasculitis; medium-vessel vasculitis such as polyarteritis nodosa and Kawasaki disease; large-vessel vasculitis, namely, giant cell arteritis and Takayasu arteritis; variable-vessel vasculitis such as Behcet disease and Cogan syndrome; and vasculitis associated with systemic diseases including rheumatoid arthritis, lupus vasculitis, and sarcoid vasculitis. Vasculitis can also be secondary to drugs, infection, underlying systemic disease, or trauma. Therefore, a diagnosis of vasculitis cannot be based on histologic ground alone. Clinical pathologic correlation is necessary.
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Affiliation(s)
- Mai P. Hoang
- Professor of Pathology, Harvard Medical School, Director of Dermatopathology, Massachusetts General Hospital, Boston, MA USA
| | - Maria Angelica Selim
- Professor of Pathology and Dermatology, Director, Dermatopathology Unit, Duke University Medical Center, Durham, NC USA
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248
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Kent BD, d'Ancona G, Fernandes M, Green L, Roxas C, Thomson L, Nanzer AM, Kavanagh J, Agarwal S, Jackson DJ. Oral corticosteroid-sparing effects of reslizumab in the treatment of eosinophilic granulomatosis with polyangiitis. ERJ Open Res 2020; 6:00311-2019. [PMID: 31984211 PMCID: PMC6970182 DOI: 10.1183/23120541.00311-2019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/18/2019] [Indexed: 01/21/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare but devastating vasculitis characterised by perivascular eosinophilic inflammation, severe asthma, peripheral eosinophilia and sinonasal disease, frequently complicated by cardiac, neurological or renal involvement [1, 2]. The mainstay of therapy for EGPA is use of systemic corticosteroids (OCS), with or without concomitant immunosuppression with methotrexate, azathioprine, cyclophosphamide or rituximab [3, 4]. The long-term use of these agents is associated with significant drug-related morbidity and the risk of relapse in EGPA patients remains significant despite treatment [1, 5]. Interleukin (IL)-5 is a critical cytokine regulating eosinophil development, migration and activation [2]. In EGPA, high doses of the IL-5 neutralising antibody mepolizumab lead to improved disease control and reduced requirement for OCS therapy, with an excellent safety profile [6, 7]. Reslizumab is another IL-5 neutralising antibody currently licensed for the treatment of severe eosinophilic asthma [8]; however, there are – to our knowledge – no published data exploring the utility of reslizumab in the management of EGPA. Here, we report clinical and patient-reported outcomes in a cohort of treatment-refractory, OCS-dependent EGPA patients with severe asthma commenced on reslizumab. Blockade of interleukin-5 with reslizumab appears to have significant oral corticosteroid sparing effects in patients with eosinophilic granulomatosis with polyangiitis and severe eosinophilic asthmahttp://bit.ly/2D2yYSK
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Affiliation(s)
- Brian D Kent
- Guy's Severe Asthma Centre, Guy's and St Thomas' Hospitals, London, UK.,Asthma UK Centre, King's College London, London, UK
| | - Grainne d'Ancona
- Guy's Severe Asthma Centre, Guy's and St Thomas' Hospitals, London, UK.,Asthma UK Centre, King's College London, London, UK
| | - Mariana Fernandes
- Guy's Severe Asthma Centre, Guy's and St Thomas' Hospitals, London, UK
| | - Linda Green
- Guy's Severe Asthma Centre, Guy's and St Thomas' Hospitals, London, UK
| | - Cris Roxas
- Guy's Severe Asthma Centre, Guy's and St Thomas' Hospitals, London, UK
| | - Louise Thomson
- Guy's Severe Asthma Centre, Guy's and St Thomas' Hospitals, London, UK
| | - Alexandra M Nanzer
- Guy's Severe Asthma Centre, Guy's and St Thomas' Hospitals, London, UK.,Asthma UK Centre, King's College London, London, UK
| | - Joanne Kavanagh
- Guy's Severe Asthma Centre, Guy's and St Thomas' Hospitals, London, UK
| | - Sangita Agarwal
- Dept of Rheumatology, Guy's and St Thomas' Hospitals, London, UK
| | - David J Jackson
- Guy's Severe Asthma Centre, Guy's and St Thomas' Hospitals, London, UK.,Asthma UK Centre, King's College London, London, UK
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249
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Berti A, Cornec D, Casal Moura M, Smyth RJ, Dagna L, Specks U, Keogh KA. Eosinophilic Granulomatosis With Polyangiitis: Clinical Predictors of Long-term Asthma Severity. Chest 2020; 157:1086-1099. [PMID: 31958440 DOI: 10.1016/j.chest.2019.11.045] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 11/14/2019] [Accepted: 11/30/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The long-term clinical course of asthma in patients with eosinophilic granulomatosis with polyangiitis (EGPA) remains unclear. We aimed to characterize long-term asthma in EGPA and to identify baseline predictors of long-term asthma severity. METHODS This retrospective cohort study included patients who fulfilled standardized criteria for EGPA who were followed up in a single referral center between 1990 and 2017. Baseline and 3 (± 1) years of follow-up clinical, laboratory, and pulmonary function data were analyzed. RESULTS Eighty-nine patients with EGPA and a documented asthma assessment at baseline and at 3 years from diagnosis were included. Severe/uncontrolled asthma was observed in 42.7% of patients at diagnosis and was associated with previous history of respiratory allergy (P < .01), elevated serum total IgE levels (P < .05), and increased use of high-dose inhaled corticosteroids (ICSs; P < .05) and oral corticosteroids (OCSs; P < .001) for respiratory symptoms the year before the EGPA diagnosis. During follow-up, an improvement or worsening in asthma severity was noted in 12.3% and 10.1% of patients, respectively. Severe/uncontrolled asthma was present in 40.5% of patients at 3 years and was associated with increased airway resistance on pulmonary function tests (PFTs; P < .05). Long-term PFTs did not improve during long-term follow-up regardless of ICS or OCS therapy. Multivariate binary logistic regression results indicated that severe rhinosinusitis (P = .038), pulmonary infiltrates (P = .011), overweight (BMI ≥ 25 kg/m2; P = .041), and severe/uncontrolled asthma at vasculitis diagnosis (P < .001) independently predicted severe/uncontrolled asthma at the 3-year end point. CONCLUSIONS In patients with asthma with EGPA, long-term severe/uncontrolled asthma is associated with baseline pulmonary and ear, nose, and throat manifestations but not with clear-cut vasculitic features.
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Affiliation(s)
- Alvise Berti
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN; Rheumatology Department, Santa Chiara Hospital, and Center for Integrative Biology, University of Trento, Trento, Italy
| | - Divi Cornec
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN; INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Centre Hospitalier Universitaire de Brest, Brest, France
| | - Marta Casal Moura
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Robert J Smyth
- Department of Pulmonary Medicine, Boston Medical Center, Boston, MA
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Karina A Keogh
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
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Berti A, Boukhlal S, Groh M, Cornec D. Eosinophilic granulomatosis with polyangiitis: the multifaceted spectrum of clinical manifestations at different stages of the disease. Expert Rev Clin Immunol 2020; 16:51-61. [PMID: 31762336 DOI: 10.1080/1744666x.2019.1697678] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Introduction: Eosinophilic granulomatosis with polyangiitis (EGPA) usually occurs in patients with late-onset asthma and sustained peripheral blood eosinophilia and classically presents with a clinical multifaceted spectrum of manifestations, which may vary at the different stages of the natural history of the disease.Areas covered: We reviewed EGPA clinical presentation, focusing on clinical manifestations at three different phases of the disease: 1/before the development of overt vasculitis, 2/at vasculitis diagnosis and 3/during the long-term follow-up. An update on current classification criteria and recent therapeutic advances has been provided as well.Expert opinion: Asthma, chronic rhinosinusitis and blood eosinophilia could anticipate the overt vasculitis for years. An atopic background may be present in a subset of patients (25-30%), while ANCA presence varies between 10 and 40%. Systemic vasculitis rapidly occurs and clinical features demonstrating vasculitis processes (neuropathy, purpura, scleritis, alveolar hemorrhage and glomerulonephritis) develop along with systemic symptoms (50%). After vasculitis resolution, asthma remains severe in up to 50% of patients and incidence of isolated-asthma and rhinosinus exacerbations remains constantly high. Different sets of classification criteria have been published so far, and DCVAS diagnostic criteria will be presented soon. Interleukin-5 blockers seem to be promising to control the disease and to spare corticosteroids.
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Affiliation(s)
- Alvise Berti
- Department of Rheumatology, Santa Chiara Hospital, Trento, Italy.,Department of Cellular, Computational and Integrative Biology-CIBIO, University of Trento, Trento, Italy
| | - Sara Boukhlal
- INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, CHU de Brest, Brest, France
| | - Matthieu Groh
- Department of Internal Medicine, Hôpital Foch, National Referral Center for Hypereosinophilic Syndrome (CEREO), Suresnes, France
| | - Divi Cornec
- INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, CHU de Brest, Brest, France
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