The spectrum of vasculitis: clinical, pathologic, immunologic and therapeutic considerations

Comparative clinical and epidemiological study of hypersensitivity vasculitis versus Henoch-Schönlein purpura in adults

OBJECTIVES

To assess the incidence and clinical features of adults with hypersensitivity vasculitis (HV) and Henoch-SchOnlein purpura (HSP) in a well-defined population.

METHODS

Retrospective study of an unselected population of adult patients (>20 years) with biopsy-proven cutaneous vasculitis diagnosed as having HV or HSP who presented at a primary hospital between 1988 and 1997. Patients with cutaneous vasculitis secondary to collagen vascular diseases, neoplasia, severe infections, and those with other well-defined clinical entities were excluded. Patients were classified as having either HV or HSP according to the criteria proposed by Michel et al (J Rheumatol 1992;19:721-28).

RESULTS

Fifty-six adults (35 men/21 women), were classified as having HV and 27 adults as having HSP (19 men/8 women). The annual incidence rate for HV was 29.7/million and 14.3/million for HSP. At the onset of the disease, adults with HSP were younger than those with HV (46+/-18 years versus 59+/-18 years in HV; P = .005). Precipitating events were found in 50% of HV and in 30% of HSP patients. A history of drug therapy before the onset of vasculitis was found in 46% of HV and in 26% of HSP (P = .074). At disease onset, skin lesions were the most common manifestation in both groups. During the disease course, adults with HSP had joint manifestations more commonly (59% in HSP v25% in HV; P < .003) and more gastrointestinal (82% v 5% in HV; P < .001) and renal complications (48% v 5% in HV; P < .001). HSP subjects required more aggressive therapy consisting of steroids (P < .001) or cytotoxic agents (P < .001). After 37+/-28 (median, 31) months, complete recovery was observed in 98% of adults with HV. After 40+/-27 (median, 36) months, complete recovery was observed in only 67% of adults with HSP (P < .001). Renal insufficiency was observed in 8% of adults with HSP.

CONCLUSIONS

In adults, HV and HSP as defined by these criteria, behave as two well-differentiated diseases. HV has a milder course and lack of severe complications, and HSP a higher risk of gastrointestinal and renal complications.

Vasculitis confined to the peripheral nerve and skin: a variant of non-systemic vasculitic neuropathy

We describe a patient presenting with vasculitic neuropathy associated with cutaneous vasculitis in the absence of other clinical or laboratory evidence of the underlying systemic vasculitis, and showing a favourable prognosis. Although the early proposed criteria for the diagnosis of non-systemic vasculitic neuropathy (NSVN) exclude the involvement of extraneural tissues, the condition observed in our patient might represent a variant of NSVN, with the vasculitis confined to the small vessels in both the peripheral nerve and the skin.

Churg-Strauss syndrome. Clinical study and long-term follow-up of 96 patients

Churg-Strauss syndrome (CSS) is a systemic vasculitis characterized by the presence of asthma, hypereosinophilia, and necrotizing vasculitis with extravascular eosinophil granulomas. In this retrospective study of 96 patients between 1963 and 1995, we analyzed clinical manifestations, identified prognostic factors, and assessed the long-term outcome. CSS was diagnosed when asthma, hypereosinophilia > 1,500/mm3 or > 10%, and clinical manifestations consistent with systemic vasculitis, with or without histologic evidence, were present. Asthma was the most frequently observed manifestation at presentation, with mononeuritis multiplex the second. Other common manifestations were weight loss, fever, myalgia, skin involvement, paranasal sinusitis, arthralgia, pulmonary infiltrate, and gastrointestinal involvement. Mean eosinophilia at presentation was 7.193 +/- 6.706/mm3; ANCA, present in 20 of 42 (47.6%) patients, predominantly gave the perinuclear labeling pattern. All the patients were treated with corticosteroids alone or in combination with cyclophosphamide or plasma exchanges. Clinical remission was obtained in 91.5%; 22 (25.6%) patients relapsed. Twenty-three patients died during follow-up: 11 of these deaths were directly due to vasculitis. The presence of severe gastrointestinal tract or myocardial involvement was significantly associated with a poor clinical outcome. The long-term prognosis of CSS is good and does not differ from that of polyarteritis nodosa, although most patients need low doses of oral corticosteroids for persistent asthma, even many years after clinical recovery from vasculitis.

Cutaneous vasculitis in children and adults. Associated diseases and etiologic factors in 303 patients

Cutaneous vasculitis (CV), a condition characterized by palpable purpura and nonspecific histopathologic findings, presents a diagnostic and therapeutic challenge because it may be a primary disorder or it may be a cutaneous manifestation of another entity, such as systemic necrotizing vasculitis, connective tissue disease, systemic bacterial infection, or malignancy. We studied 303 unselected patients (172 adults and 131 children) with CV to assess the disease associations and etiologic factors, to identify the frequency of primary and secondary CV in different age-groups, and to characterize features that help to distinguish between primary and secondary CV. Of the 131 children, 130 had primary CV: Henoch-Schönlein purpura (HSP) in 116 and hypersensitivity vasculitis (HV) in 14. In contrast, of the 172 adults, only 120 had primary CV: HSP in 39, HV in 70, and essential mixed cryoglobulinemia in 11. CV was a manifestation of systemic necrotizing vasculitis in 23 adults (polyarteritis nodosa in 17, Wegener granulomatosis in 4, and Churg-Strauss syndrome in 2). CV was secondary to other processes in 29 adults: in 20 patients CV was associated with connective tissue disease or another autoimmune or rheumatic disease, in 5 patients CV was a manifestation of severe bacterial infection, especially bacterial endocarditis (4 cases), and in the other 4 patients CV was the presenting symptom of an underlying malignancy. The patients for whom CV was a manifestation of systemic necrotizing vasculitis or secondary to a connective tissue disease, severe bacterial infection, or malignancy had clinical and laboratory data suggestive of the associated disorder. The clinical picture and outcome of primary CV in both children and adults were benign. By contrast, the prognosis of patients with CV in the context of systemic necrotizing vasculitis or secondary to other entities depended on the primary process. Given the different disease association in children and adults, we propose a simple diagnostic workup in children with CV. By contrast the diagnostic approach in adults with CV should be more cautious and the workup more extensive. The early differentiation between primary CV, secondary CV, and CV presenting as a symptom of systemic necrotizing vasculitis, especially in adults, is of paramount importance for an adequate diagnosis and appropriate treatment.

Cutaneous small-vessel vasculitis

Cutaneous small-vessel vasculitis (CSVV) refers to a group of disorders usually characterized by palpable purpura; it is caused by leukocytoclastic vasculitis of postcapillary venules. CSVV can be idiopathic or can be associated with a drug, infection, or underlying systemic disease. Initially, the pathogenesis of CSVV is immune complex related, but in its later stages different pathogenetic mechanisms may intensify the reaction and lymphocytes may predominate in the infiltrate. Cure requires elimination of the cause (ie, drugs, chemicals, infections, food allergens) when possible, as well as therapy with nonsteroidal antiinflammatory agents, corticosteroids, dapsone, potassium iodide, fibrinolytic agents, aminocaproic acid, immunosuppressive agents (ie, cyclophosphamide, azathioprine, methotrexate, cyclosporine) or even monoclonal antibodies, depending on disease severity.

Vasculitis-susceptible genes in mice with a deficit in Fas-mediated apoptosis

Autoimmune diseases show complex pathological manifestations, which frequently involve systemic vasculitis. This complication is understood to be a manifestation of advanced disease, or to represent distinct entities, restricted by genetic and/or environmental factors. An MRL/Mp strain of mice bearing the Fas deletion mutant gene, lpr (MRL/lpr), spontaneously develop systemic vasculitis coincidentally with glomerulonephritis, arthritis and sialoadenitis, but a C3H/HeJ-lpr/lpr (C3H/lpr) strain does not. Thus, this is a suitable model for analyzing the genetic basis of vasculitis in autoimmune diseases. To genetically dissect these complex pathological manifestations, a linkage analysis of each lesion with polymorphic microsatellite markers was performed by using MRL/lpr x (MRL/lpr x C3H/lpr)F1 backcross mice. Vasculitis-susceptible gene loci were mapped on chromosomes 3 and 4, which were not associated with glomerulonephritis, arthritis and sialoadenitis. These results indicate that systemic vasculitis in MRL/lpr mice may be under the control of host genes which are different from those for other autoimmune diseases.

Cutaneous allergic vasculitis: clinicopathological characterization and identification of apoptosis

To elucidate the clinicopathological features of cutaneous allergic (leukocytoclastic) vasculitis (CAV), biopsied skin tissues of 32 patients with CAV were examined immunohistopathologically and compared with the main clinical features. Additionally, to obtain some clues to better understand the roles of infiltrating cells, particularly neutrophils in CAV, apoptosis and related antigens were investigated in vivo. The 32 patients with CAV were divided into two groups based on their clinical course: (i) non-recurrent (group I; nine cases); and (ii) recurrent (group II; 23 cases). Immunohistopathologically, group I was characterized by stereotypical necrotizing changes of CAV with fibrin exudation of small blood vessels in the upper cutis, and group II was characterized by CAV and fibrous thickening of the vascular walls with significant infiltration of CD3+, UCHL-1+ T cells. Group II was subdivided further: groups IIa (15 cases) and IIb (eight cases); that is, the former was notable for necrotizing changes of CAV, which tended to spread into the proper corium down to the lower cutis; whereas the latter exhibited considerably less marked histological changes of CAV without any spread to the lower cutis. In a comparison of the clinical data among the three groups, there were considerable differences in age, clinical course, localization of purpura and associated disease. In particular, group II showed a high frequency of connective tissue diseases. The presence of apoptosis was seen in a considerable number of neutrophils, and some nuclear debris turned out to be apoptotic bodies by the in situ terminal deoxytransferase (TdT)-catalyzed DNA nick end-labeling (TUNEL) method and electron microscopy. By combining immunohistochemistry with TUNEL, the majority of apoptotic neutrophils and nuclear debris was seen to be ingested by macrophages. In immunohistochemical examinations for apoptosis-related bcl-2 protein and Fas antigen, bcl-2 was recognized only in the cytoplasm of infiltrating T cells, and Fas was positively stained on the cellular membranes of infiltrating T cells and neutrophils in a scattered fashion. Thus, a novel method for neutrophil disposal in CAV was suggested.

Acute transverse myelitis and primary urticarial vasculitis

We report the case of a 56-year-old man with severe normocomplementaemic primary urticarial vasculitis for 16 years. Nine and 11 years after the onset of the symptoms, he developed two severe neurological complications, seizure and transverse myelitis, that must be attributed to the vasculitis. Transverse myelitis has been reported in other systemic diseases, particularly lupus erythematosus, but this is the first case of transverse myelitis complicating urticarial vasculitis.

Multiple myeloma-associated amyloidosis and giant cell arteritis

Primary systemic amyloidosis has been associated with the development of symptoms and clinical features characteristic of polymyalgia rheumatica and/or giant cell arteritis (GCA). Case reports of this clinical entity have been published, stating that the amyloid deposition leads to the symptoms of vasculitis. In this report, we present a second case in the English literature of a patient presenting with multiple myeloma-associated amyloidosis and GCA. This is the first case in which the histopathologic findings are described in enough detail to suggest a pathogenic relationship between the two diseases.

Polyarteritis nodosa, microscopic polyangiitis and Churg-Strauss syndrome

Polyarteritis nodosa (PAN), first described by Küssmaul and Maier, is a well-known form of necrotizing angiitis whose manifestations are weight loss, fever, asthenia, peripheral neuropathy, renal involvement, musculoskeletal and cutaneous manifestations, hypertension, gastrointestinal tract involvement, and cardiac failure. Recently individualized from PAN, microscopic polyangiitis (MPA) is a systemic vasculitis of small-size vessels whose clinical manifestations are very similar to those of PAN, but it is characterized by the presence of rapidly progressive glomerulonephritis (RPGN), which is nearly constant, and pulmonary involvement usually absent in PAN. Churg Strauss syndrome (CSS) is a disorder characterized by hypereosinophilia and systemic vasculitis similar to that of PAN and occurring in individuals with asthma and allergic rhinitis. Considering the etiologies of PAN, primary and secondary vasculitides can also be distinguished because PAN can be the consequence of hepatitis B virus (HBV) infection and sometimes of other etiologic agents. The prognosis of systemic vasculitides has been transformed by corticosteroids that are, except in HBV-related PAN, the basic treatment. Immunosuppressive drugs, especially cyclophophamide, have also contributed to improving the prognosis, but their precise role in the management of these vasculitides is still being elucidated.

Childhood vasculitis

Vasculitis can and does occur in childhood. Apart from the relatively common vasculitides (Henoch-Schönlein purpura, Kawasaki disease and in world wide terms Takayasu disease) there are a number of important but comparatively rare disorders affecting children. These include macroscopic and microscopic polyarteritis, cutaneous polyarteritis, Wegener's granulomatosis, Churg-Strauss syndrome, primary angiitis of the central nervous system, hypersensitivity angiitis, hypocomplimentaemic urticarial vasculitis, vasculitis associated with various connective tissue disorders and vasculitis associated with conditions such as Behçets syndrome, familial Mediterranean fever and Cogan's syndrome. Distinguishing these conditions from other disorders is often difficult and requires clinical acumen and appropriate investigative procedures. With modern therapeutic agents, it is possible to implement appropriate therapy but in spite of this, there remains a not inconsequential morbidity and mortality.

Systemic diseases involving the orbit

A variety of systemic pathological processes may involve the eye and the surrounding orbital adnexae. CT and MRI of the orbit have become useful clinical adjuvants, not only in establishment of the diagnosis, but also in suggesting the appropriate clinical treatment, sometimes preventing needless biopsy. Grave's disease, Wegener's granulomatosis, and sarcoidosis may all present initially with orbital disease before the onset of systemic manifestations. Idiopathic inflammatory disease of the orbit and lymphoproliferative disease of the orbit continue to remain radiological and clinical challenges. The article discusses the CT and MRI appearance of many of the common systemic diseases in adults with attention to features useful in clinical practice as well as in differential diagnosis.

Wegener's granulomatosis of the head and neck

Among the more puzzling non-neoplastic necrotizing lesions of the head and neck area is Wegener's granulomatosis. This is a condition of unknown cause that may present (in the head and neck area) with ulceration of the nasal septum, sinus mucosa, oral mucosa, or external ear canal, or even destruction of the vocal cord. Diagnosis depends on the pathologic finding of a characteristic inflammatory reaction pattern (which, in its best-developed form, includes necrosis, granulomatous inflammation, and vasculitis) and the serum finding of an elevated antinuclear cytoplasmic antigen. Treatment is principally medical, with the use of powerful immunosuppressive agents. Distinction from other conditions that may mimic Wegener's granulomatosis (such as malignant lymphoma and infections) is of critical importance in constructing an appropriate treatment strategy.

Wegener's granulomatosis

Clinical manifestations of Wegener's granulomatosis are nonspecific and indistinguishable from a variety of neoplastic, infectious, and inflammatory diseases. Ophthalmic disease is the presenting feature in nearly one sixth of patients with Wegener's granulomatosis and will ultimately develop in a majority. The discovery of antineutrophil cytoplasmic antibodies, particularly antiproteinase-3, has changed the clinical approach to evaluating patients suspected of having Wegener's granulomatosis. These antibodies are distinguished from other related autoantibodies because they produce a coarse granular pattern of cytoplasmic staining on indirect immunofluorescence with ethanol-fixed neutrophils. Treatment of Wegener's granulomatosis with oral cyclophosphamide and corticosteroids has decreased morbidity and improved survival, but side effects from long-term immunosuppressive therapy are common and sometimes serious. The effectiveness of trimethoprim-sulfamethoxazole in decreasing the number and severity of recurrences of Wegener's granulomatosis is being investigated. It remains to be determined if wide use of trimethoprim-sulfamethoxazole in limited Wegener's granulomatosis could further improve the quality of life for some patients.

Demonstration of microaneurysms at the interlobular arteries of the kidneys in microscopic polyangiitis: a three-dimensional study

Aneurysms, mostly saccular, of the medium-sized muscular arteries are frequently encountered in classic polyarteritis nodosa, whereas their occurrence in smaller arteries is unclear. The objective of this study is to clarify the three-dimensional morphology of the small-sized muscular arteries involved in microscopic polyangiitis (MPA). Six autopsy cases of MPA of the acute inflammatory stage were chosen. Using serial paraffin-embedded sections of the kidney, vasculitic lesions observed in the interlobular arteries were three-dimensionally reconstructed. All of the 19 lesions showed microaneurysms, of which 18 were sausage-shaped and the other was saccular. In the former type, average outer diameter at the most expanded point was 235.4 +/- 83.8 microm (mean +/- SD), which was 2.78 +/- 0.73 times that of an uninvolved adjacent arterial diameter. The major axis-minor axis ratio in a cross-aneurysmal section was 1.17 +/- 0.16, indicating rather regular centrifugal expansion of the aneurysm. The aneurysmal length was 742.7 +/- 254.8 microm. These sausage-type aneurysms showed whole circumferential vasculitic involvement, whereas the saccular-type aneurysm contained an uninvolved arterial portion. In both types, the luminal spaces showed similar three-dimensional features to the outer surface of microaneurysms It was concluded that the interlobular arteries of the kidneys in MPA were characterized by formation of microaneurysms, most of which were sausage-shaped

Anastomotic aneurysms after surgical treatment of Takayasu's arteritis: a 40-year experience

PURPOSE

To evaluate the clinical characteristics of anastomotic aneurysms that develop in surgically treated patients with Takayasu's arteritis.

METHODS

Among 103 patients with Takayasu's arteritis treated surgically over 40 years, 91 patients with 259 anastomoses (allowing for exclusion of 12 operative deaths) participated in follow-up study from 1 month to 37.3 years with a mean value +/- SEM of 17.3 +/- 1.1 years with a follow-up completion rate of 93% at 30 years. The clinical characteristics of anastomotic aneurysms were clarified, and the influences of several factors (sites of anastomoses, occlusive or aneurysmal disease, suture material, preoperative systemic inflammation, and administration of corticosteroids) on formation of anastomotic aneurysms were analyzed by means of life-table method and Cox regression analysis.

RESULTS

Twenty-two uninfected anastomotic aneurysms were found among 14 patients (22 of 259 anastomoses, 8.5%). The interval between the previous operation and diagnosis varied from 1.6 to 30 years with a mean value +/- SEM of 9.8 +/- 1.8 years. The cumulative incidence of anastomotic aneurysm at 20 years was 12.0%. Systemic inflammation or steroid administration had little influence on formation of anastomotic aneurysm. Instead, anastomotic aneurysm tended to occur after operations for aneurysmal lesions.

CONCLUSIONS

Anastomotic aneurysm can occur anytime after operations for Takayasu's arteritis. The development of anastomotic aneurysm is not influenced by any factor specific to this disease except the presence of an aneurysmal lesion.

Systemic vasculitis. Diagnostic clues to this confusing array of diseases

Systemic vasculitis can be difficult to recognize because of the many types of the disease and the conditions that can mimic it. However, early identification and initiation of treatment (often empirical) are important to avoid severe morbidity. In this symposium article, Dr Bush clearly describes the most common types of vasculitis according to current nomenclature based on the size of affected vessels. Illustrations of common signs of the various types of vasculitis are also included.

Alternative therapies for vasculitis and proliferative nephritides: the role of cyclic AMP elevating agents

Cytoprotection by E-prostaglandins, working by elevation of intracellular cyclic AMP, is a natural physiological mechanism. When agents that elevate cAMP are used in pharmacological regimens they have potent anti-inflammatory effects that could be used to good effect as adjuncts for the control of vasculitides/nephritides.

Polyarteritis nodosa, microscopic polyangiitis, and Churg-Strauss syndrome: clinical aspects, neurologic manifestations, and treatment

Polyarteritis nodosa (PAN), microscopic polyangiitis (MPA), and Churg-Strauss syndrome (CSS) all have neurologic symptoms and share characteristics and outcomes. Clinical aspects, neurologic manifestations, and treatment of these three diseases are examined in this article.

Radiographic features of central nervous system vasculitis

Central nervous system (CNS) vasculitis refers to primary and secondary disorders of the CNS vasculature. Most authorities agree that CNS vasculitis is a potentially serious disorder; therefore, prompt diagnosis and initiation of therapy are high priorities in treatment. Remarkable progress has been made in the diagnosis, evaluation, and treatment of this disorder. This article examines many aspects of the radiographic evaluation of CNS vasculitis.

Recombinant proteinase 3 (Wegener's antigen) expressed in Pichia pastoris is functionally active and is recognized by patient sera

The open reading frame of human proteinase 3 (PR3) without the prepro-peptide was cloned and expressed in Escherichia coli (rcPR3) and in Pichia pastoris (rpPR3). The 6-histidine tagged rpPR3 was efficiently secreted into culture supernatant from which it could be purified by immobilized metal chelate chromatography. Purified rpPR3 migrated as a single 32-kD band on SDS-PAGE and harboured protease activity that could be inhibited with inhibitors specific for serine-proteases. By indirect antigen-capture ELISA using rpPR3, 60% of sera from patients with Wegener's granulomatosis bound to the recombinant product, although it was not recognized in ELISA with directly coated rpPR3.

Granulomatous angiitis of the nervous system

Granulomatous angiitis of the nervous system (GANS) refers to distinctive clinicopathologic disorders with the essential feature of granulomatous inflammation of cerebral and spinal vessels, accompanied by multinucleate giant cells and epithelioid cells. This article reviews and examines the clinical, laboratory, and neuropathologic findings of patients with granulomatous angiitis.

Necrotizing peripheral nerve vasculitis

Necrotizing vasculitis of the type in polyarteritis nodosa is a treatable cause of neuropathy. The diagnosis must be confirmed histologically by demonstration of characteristic arterial lesions in nerve and muscle biopsy specimens. Ischemic neuropathy which results from occlusion of nerve arteries in polyarteritis nodosa also occurs as a consequence of inflammatory arterial lesions in other connective tissue disorders, in some infectious neuropathies and in patients with malignant lymphomas. Patients with vasculitic neuropathy may also present with isolated peripheral neuropathy.

Cerebral lupus vasculopathy. Mechanisms and clinical relevance

The most common neuropathological findings in SLE are a small vessel cerebral vasculopathy and microinfarcts. These findings may reflect the end result of repeated episodes of acute inflammation in the small vessels in the brain. There is experimental support for the local Shwartzman reaction as a paradigm to explain some of the CNS manifestations in SLE. Activation or "priming" of cerebral microvascular endothelial cells by anticardiolipin antibodies or other immunoglobulins in concert with intravascular activation of the complement system may combine to elicit leukothrombosis in the brain. Therapies aimed at inhibiting leukocyte-endothelial cell interactions in the brain may be of use in CNS lupus.

Cardiac involvement in childhood polyarteritis nodosa

In this report, we evaluated the cardiac findings of 15 children with polyarteritis nodosa. The age range of the patients was 4-14 years; with a mean of 10 years. All have had systemic involvement of the disease. The most common findings in cardiac evaluation were diminished left ventricular systolic functions and mild mitral and/or tricuspid valve regurgitation. One patient had pericardial thickening with no effusion. One had sinus tachycardia. There were no signs of myocardial infarction or ischemia clinically or electro-cardiographically. In conclusion, we did not find cardiac complications, such as pericarditis or myocardial infarction, to be as frequent as in previous reports. However, even in asymptomatic patients, systolic dysfunction or valvular involvement were common findings in patients with polyarteritis nodosa, which were not reported previously. These findings may be due to the histological changes of the myocardium or atrioventricular valves. Although these were not severe and fatal lesions, long-term follow-up of these patients with echocardiography may help to determine the course of cardiac involvement.

Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks

Staphylococcus aureus has long been recognized as an important pathogen in human disease. Due to an increasing number of infections caused by methicillin-resistant S. aureus (MRSA) strains, therapy has become problematic. Therefore, prevention of staphylococcal infections has become more important. Carriage of S. aureus appears to play a key role in the epidemiology and pathogenesis of infection. The ecological niches of S. aureus are the anterior nares. In healthy subjects, over time, three patterns of carriage can be distinguished: about 20% of people are persistent carriers, 60% are intermittent carriers, and approximately 20% almost never carry S. aureus. The molecular basis of the carrier state remains to be elucidated. In patients who repeatedly puncture the skin (e.g., hemodialysis or continuous ambulatory peritoneal dialysis [CAPD] patients and intravenous drug addicts) and patients with human immunodeficiency virus (HIV) infection, increased carriage rates are found. Carriage has been identified as an important risk factor for infection in patients undergoing surgery, those on hemodialysis or CAPD, those with HIV infection and AIDS, those with intravascular devices, and those colonized with MRSA. Elimination of carriage has been found to reduce the infection rates in surgical patients and those on hemodialysis and CAPD. Elimination of carriage appears to be an attractive preventive strategy in patients at risk. Further studies are needed to optimize this strategy and to define the groups at risk.

Classification and epidemiology of the vasculitides

The systemic vasculitides are rare inflammatory conditions of blood vessel walls. A number of different classification schemes have been published since the first in 1952. The important developments have been the recognition of dominant blood vessel size, the distinction between primary and secondary vasculitis and the incorporation of pathogenic markers such as anti-neutrophil cytoplasmic antibodies. In 1990 the American College of Rheumatology (ACR) published criteria for the diagnosis of polyarteritis nodosa, Churg-Strauss syndrome, Wegener's granulomatosis, hypersensitivity vasculitis, Schönlein-Henoch purpura, giant cell arteritis and Takayasu arteritis. Sensitivity and specificity rates varied considerably: 71.0-95.3% for sensitivity and 78.7-99.7% for specificity. The criteria were not tested against the general population or against patients with other connective tissue diseases or rheumatic conditions. Four years later the Chapel Hill Consensus Conference (CHCC) produced definitions for the major types of vasculitis, however, these have proved controversial. Comparison in unselected patients with systemic vasculitis (in particular polyarteritis nodosa and microscopic polyangiitis) has shown that the ACR criteria and CHCC definitions identify different patients. The systemic vasculitides are somewhat more common than previously believed. The overall annual incidence approaches 40/million adults. The most common form of primary systemic vasculitis is giant cell arteritis; Wegener's granulomatosis, microscopic polyangiitis and Churg-Strauss syndrome have similar incidences. Classical polyarteritis nodosa and Takayasu arteritis are very rare in the UK.

Vasculitis associated with connective tissue disease

Vasculitis, one of the clinical features shared by connective tissue diseases, should be considered when signs and symptoms are observed that may result from tissue ischaemia due to damaged vessels. The lesions seem to result from specific and non-specific immunopathogenic mechanisms targeted at the vascular endothelium. Because of the therapeutic implications it is the physician's responsibility to document its presence and the extent of organ involvement. Prompt institution of immunosuppressive drugs may be lifesaving. On the other hand there are some forms of vasculitis accompanying connective tissue disease which are entirely benign. Patients with infarctions of extremities and progressive functional disturbances of the central nervous system or internal organs because of vasculitis should be treated with high dosages of corticosteroids in combination with cytostatic drugs. Remissions are frequently obtained within three to six months of initiation of treatment and can be maintained with a less aggressive treatment regimen.

Henoch-Schönlein purpura in adulthood and childhood: two different expressions of the same syndrome

OBJECTIVE

To assess the possible differences between children (< or = 20 years) and adults (> 20 years) with Henoch-Schönlein purpura (HSP).

METHODS

A retrospective study of an unselected population of patients with HSP who presented to our teaching hospital between 1975 and 1994. Patients were classified as having HSP according to the criteria proposed by Michel et al.

RESULTS

Following the above-mentioned criteria, 162 white patients (113 male and 49 female) were classified as having HSP; 46 of the patients were adults (mean +/- SD age 53.2 +/- 16.9 years) and 116 were children (6.9 +/- 3.1 years). We were unable to identify any precipitating event in 72% of the adults and 66% of the children. The frequency of previous drug treatment, primarily antibiotics or analgesics, was similar in both groups, whereas previous upper respiratory tract infection was more frequent among the children (P < 0.02). At symptom onset, cutaneous lesions were the main clinical manifestation in both groups. However, adults had a lower frequency of abdominal pain (P < 0.008) and fever (P < 0.01), and a higher frequency of joint symptoms (P < 0.001). During the clinical course, adults had more frequent (P < 0.001) and severe renal involvement. An increased erythrocyte sedimentation rate was also more frequent in the adults (P < 0.001). Adults required more aggressive therapy, consisting of steroids (P < 0.002) and/or cytotoxic agents (P < 0.001). The outcome was relatively good in both age groups, with complete recovery in 107 children (93.9%) and in 33 adults (89.2%) after a mean +/- SD followup of 19.4 +/- 27.7 (median 12) and 21.8 +/- 33.5 (median 15) months, respectively.

CONCLUSION

In adulthood, HSP, as defined by the criteria proposed by Michel et al, represents a more severe clinical syndrome, with a higher frequency of renal involvement. However, the final outcome of HSP is equally good in patients of both age groups.

Classification and management of necrotising vasculitides

Systemic vasculitides are a heterogeneous group of diseases. Having only a partial understanding of the aetiologies and pathogenetic mechanisms of these disorders explains the difficulties encountered in classifying and treating patients. Nevertheless, some important points have been established. Classification is mainly based on the size of vessels affected and, from the polyarteritis nodosa group, microscopic polyangiitis (MPA) has been separated from classic polyarteritis nodosa (c-PAN). The latter is a rare disease which is, in a small number of cases, the consequence of hepatitis B or C virus (HBV/HCV) infection. In the other cases of c-PAN and in MPA, the aetiology is unknown as for Churg-Strauss syndrome (CSS) and Wegener's granulomatosis (WG). MPA, CSS and WG are mainly antineutrophil cytoplasmic antibodies (ANCA)-related vasculitides. ANCA play a part in the pathogenesis of diseases and are sometimes useful markers for diagnosis and follow-up. Vasculitis treatments should be chosen according to classification, aetiology, pathogenetic mechanisms, severity and predictable outcome. In virus-associated vasculitides, treatment is based on the combination of antiviral agents and symptomatic or immunomodulating therapies. HBV-related PAN and HCV-related cryoglobulinaemia respond to interferon-alpha and to plasma exchange. Responses are excellent in HBV-PAN but usually partial in HCV-cryoglobulinaemia, and relapses occur in the majority of cases. MPA, c-PAN, WG and other vasculitides respond to corticosteroids and cytotoxic agents, mainly cyclophosphamide. Treatment duration and ways of administration can vary from one disease to another. Plasma exchange is not recommended as the first-line treatment. Immunoglobulins and other immunomodulating treatments are indicated in limited cases and their indications necessitate further prospective studies.

Cerebrovascular complications of rheumatic disease

Cerebral ischemia and infarction, intracerebral hemorrhage, subarachnoid hemorrhage, cerebral venous thrombosis, and cerebral vasculitis are dreaded but largely uncommon complications of most rheumatic diseases. In some conditions, however, such as the antiphospholipid syndrome or Behcet's disease, stroke may be the presenting complaint. A format for approaching the patient and localizing the cerebrovascular lesion has been presented along with a summary of the specific rheumatologic diseases implicated for each stroke subtype.

Facial heliotrope rash as the initial manifestation of acute myelomonocytic leukemia

The association of leukocytoclastic vasculitis or dermatomyositis with malignancies has been reported. We describe a patient who developed a skin rash, histologically compatible with dermatomyositis, which during the course of the disease switched to leukocytoclastic vasculitis, which was accompanied with peripheral blood pancytopenia in the absence of any specific pathological manifestation from the bone marrow three years prior to the diagnosis of acute myelomonocytic leukemia (AMML).

Polyarteritis nodosa-like inflammatory vascular changes in the pancreas and mesentery of rats treated with streptozotocin and nicotinamide

Pancreatic endocrine tumours and inflammatory vascular changes resembling those of human polyarteritis nodosa occurred simultaneously in male Holtzman rats after a single injection of streptozotocin and two injections of nicotinamide. The histomorphological appearance of the arterioles resembled that seen in vascular diseases of immunopathogenetic origin. The proximity of the vascular lesions to the hormone-producing tumour suggested that the tumour-related hormone production induced the development of the panarteritis. Streptozotocin-nicotinamide-induced vasculitis in rats was histologically similar to human polyarteritis nodosa. It may therefore provide a good animal model for the human disease.

Methotrexate management of immune-mediated cochleovestibular disorders

Immune-mediated cochleovestibular disorders continue to present a management challenge to the otolaryngologist. The traditional treatment of these disorders, corticosteroids and/or cyclophosphamide (Cytoxan), has been associated with serious and occasionally life-threatening complications. In this study we report our experience in treating 25 patients with immune-mediated cochleovestibular disorders with methotrexate, a less toxic immunosuppressive agent that has been used extensively in patients with rheumatoid arthritis. Mean duration of treatment was 12.9 months, and adverse reactions were acceptable and reversible. Hearing improved in 69.6% of patients, and vestibular symptoms subsided or improved in 80% of patients. The results of this study suggest that methotrexate treatment is effective in a substantial number of patients with immune-mediated cochleovestibular disorders and has acceptable adverse reactions. A prospective, randomized study is needed to compare the efficacy of methotrexate with that of other immunosuppressive agents.

Vasculitis in systemic lupus erythematosus

We studied the frequency, location, clinical and histopathological features, associated manifestations, and prognosis of vasculitides in a cohort of 667 SLE patients. Exclusion of patients with previous vasculitis or insufficient information left 540 patients, 194 of whom has vasculitis (incidence density: 0.053 new cases/person/year, cumulative incidence of 0.051 at one year, 0.232 at 5 years and 0.411 at 10 years). Vasculitis was confirmed by biopsy in 46 cases, by arteriography in five, and by both in three. A single episode of vasculitis occurred in 119 and two or more in 75 patients. Vasculitis was cutaneous in 160, visceral in 24, both in 10. In the first episode of cutaneous vasculitides, 111 had punctuate lesions, 32 palpable purpura, 6 urticaria, 6 ulcers, 8 papules, 5 erythematous plaques or macules confirmed with biopsy, 2 erythema with necrosis, and 1 panniculitis (plus small vessel vasculitis). Of 29 with visceral vasculitis in the first episode, 19 had mononeuritis multiplex, 5 digital necrosis, 3 large artery vasculitis of limbs, one mesenteric, and one coronary, more than one type could appear simultaneously or in subsequent episodes. Patients with vasculitis had longer disease duration and followup, younger age of onset of SLE, and were more frequently males than those without. Lupus manifestations associated with vasculitis in univariate logistic regression included myocarditis, psychosis, Raynaud's phenomenon, serositis, leukopenia, lymphopenia and pleuritis. Vasculitis also associated with the antiphospholipid syndrome. The strength of this association increased when patients with vasculitis confirmed by biopsy and/or arteriography were considered separately. Visceral vasculitis associated with increased mortality when controlled for age of onset and nephropathy.

Pathogenesis of vasculitis syndromes

The pathogenesis of vasculitis is complex and involves a variety of mechanisms acting in concert to bring about necrotizing inflammation of blood vessel walls. In recent years, there has been considerable progress in dissecting the immunologic abnormalities present in specific vasculitis syndromes. The primary immunopathogenic events that initiate the process of vascular inflammation and blood vessel damage, however, are still largely unknown. Although the cause of most vasculitis syndromes remains a mystery, advances in molecular and cellular immunology have defined many of the effector mechanisms that mediate inflammatory vascular damage. In this regard, modulation of the inflammatory response by specific cytokine and adhesion molecule antagonists is now possible and may prove beneficial in the treatment of vasculitis.

Churg-Strauss syndrome presented as multiple intracerebral hemorrhage

Intracerebral hemorrhage is an uncommon sequel of Churg-Strauss syndrome. We describe a 27 y old Taiwanese male patient who was clinicopathologically diagnosed as Churg-Strauss syndrome. The patient experienced a sudden onset of blurring of vision and slowness of motion and speech. Magnetic resonance imaging of the brain revealed lobar hemorrhage on right parieto-occipital and left parietal areas. The cause of cerebral hemorrhage was probably due to poorly controlled high blood pressure and vasculitis. He received pulse therapy of methylprednisolone and cyclophosphamide followed by oral prednisolone. His neurological symptoms responded well to such a regimen. Cerebral hemorrhage is a major cause of morbidity and death in patients with Churg-Strauss syndrome. Uncontrolled high blood pressure may cause cerebral hemorrhage. Careful monitor of blood pressure is critical for the management of Churg-Strauss syndrome patients.

Pulmonary capillaritis and alveolar hemorrhage. Update on diagnosis and management

Pulmonary vascular inflammatory disorders may involve all components of the pulmonary vasculature, including capillaries. The principal histopathologic features of pulmonary capillaritis include capillary wall necrosis with infiltration by neutrophils, interstitial erythrocytes, and/or hemosiderin, and interalveolar septal capillary occlusion by fibrin thrombi. Immune complex deposition is variably present. Patients often present clinically with diffuse alveolar hemorrhage, which is characterized by dyspnea and hemoptysis; diffuse, bilateral, alveolar infiltrates on chest radiograph; and anemia. Pulmonary capillaritis has been reported with variable frequency and severity as a manifestation of Wegener's granulomatosis, microscopic polyarteritis, systemic lupus erythematosus, Goodpasture's syndrome, idiopathic pulmonary renal syndrome, Behçet's syndrome, Henoch-Schönlein purpura, IgA nephropathy, antiphospholipid syndrome, progressive systemic sclerosis, and diphenylhydantoin use. In addition to history, physical examination, and routine laboratory studies, certain ancillary laboratory tests, such as antineutrophil cytoplasmic antibodies, antinuclear antibodies, and antiglomerular basement membrane antibodies, may help diagnose an underlying disease. Diagnosis of pulmonary capillaritis can be made by fiberoptic bronchoscopy with transbronchial biopsy, but thoracoscopic biopsy is often employed. Since many disorders can result in pulmonary capillaritis with diffuse alveolar hemorrhage, it is crucial for clinicians and pathologists to work together when attempting to identify an underlying disease. Therapy depends on the disorder that gave rise to the pulmonary capillaritis and usually includes corticosteroids and cyclophosphamide or azathioprine. Since most diseases that result in pulmonary capillaritis are treated with immunosuppression, infection must be excluded aggressively.

Systemic Lupus Erythematosus Presenting as Superior Vena Cava Syndrome Associated With Anticardiolipin Antibodies

A case of systemic lupus erythematosus (SLE) presenting as superior vena cava syndrome is pre sented. This 19-year-old woman was admitted for head ache and swelling in her face and neck. Initial evaluation revealed that she had a superior vena cava syndrome. Thoracal computed tomography (CT) and intravenous digital substraction angiography demonstrated the occlu sion in the superior vena cava. ANA and antiDNA titers were high and anticardiolipin antibodies were positive. Along with immunosuppressive treatment, she had been administered intravenous streptokinase. To our knowl edge, no SLE patient presenting with such an unusual form has been described in the English literature.

Perforation of small intestine caused by Churg-Strauss syndrome

In Churug-Strauss Syndrome (CSS), gastrointestinal tract (GIT) is an uncommon site of involvement. In addition to review of recent literature, we herein report a case of CSS with unusual involvement of GIT. The patient was being treated for idiopathic hypereosinophilic syndrome for 2 years; he later developed acute peritonitis and an emergency laparotomy revealed 3-cm-diameter perforation in the small intestine. In order to establish a correlation between the clinical features and the histopathological findings, we highlight the importance of adequate sampling and examination of mesenteric vessels in the attached mesentry in the resected specimen.

Classification, pathogenesis, and treatment of systemic vasculitis

Patients with systemic vasculitis (SV), especially Wegener's granulomatosis and microscopic polyangiitis, regularly present with renal involvement. Although considered a rare disease, either the incidence of SV is increasing or it is being increasingly recognized. Accurate classification systems are required to allow comparison of data from different groups investigating and treating these patients. Systemic vasculitis is known to be an autoimmune disease, but the mechanisms of pathogenesis have not been established, despite many studies on this topic in recent years. Most of this work has been done in vitro, although development of animal models is underway. Patient and renal survival have improved with aggressive immunosuppressive treatment, but morbidity is high and controversies remain in establishing the most effective regimens with minimum adverse effects. In this review we discuss the classification of SV, review the current knowledge of pathogenic mechanisms, and consider the relative merits of different treatment protocols.