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

Deterioration of mixed cryoglobulinemia during treatment with interferon-alpha-2a

A 60-year-old female developed mixed cryoglobulinemia associated with liver cirrhosis caused by the hepatitis C virus. During treatment with rIFN-alpha-2a, deterioration of cryoglobulinemia was recognized. The possible mechanisms underlying the deterioration are discussed.

[Kidney and vasculitis]

The kidney is affected in a variety of vasculitic syndrome. Vasculitis represent an heterogeneous group of inflammatory disease concerning vessels. They can be considered as secondary in systemic lupus erythematosus, cryoglobulinemia, rheumatoid polyarthritis but also in infectious diseases (Streptococci, hepatitis B) in malignant disease and after drugs. However, in many circumstances, no causes are found. The discovery of autoantibodies directed against components of neutrophil cytoplasm (ANCA) represent a great progress in the understanding of vasculitis. ANCA are autoantibodies directed against neutrophil lysosomial enzymes, preferentially myeloperoxidase and proteinase 3. They are frequently found in patients with idiopathic necrotizing vasculitis, systemic or localized to the kidney (Wegener granulomatosis, microscopic periarteritis, pauci-immune necrotizing glomerulonephritis, Churg and Strauss syndrome and polyarteritis nodosa). Diagnostic and prognostic values are sure, although their presence is unconstant with variable percentage in relation with the type of vasculitis. The increase of ANCA level is not always related with disease relapse. Conversely, a permanent low level means a quiescent disease. At the present time, it is not known if ANCA play a pathogenetic role or if they constitute a marker of the disease.

Churg-Strauss syndrome (allergic granulomatous angiitis) with multiple perforating ulcers of the small intestine, multiple ulcers of the colon, and mononeuritis multiplex

A case of Churg-Strauss syndrome with multiple perforations of the small intestine is described. A 31-year-old woman was admitted with a complaint of epigastric pain. She had a history of bronchial asthma. One week before admission, white blood cell count was 20,800/mm3 with 59% eosinophils. Neurological examination on admission disclosed mononeuritis multiplex with paresthesia in both the lower and upper extremities. At colonoscopy, there were scattered aphthous ulcers in the colon. Ophthalmological examination revealed allergic conjunctivitis. After admission, hypereosinophilia increased to as high as 36,000/mm3. Oral administration of prednisolone (60 mg/day) was begun. On the 3rd day of the treatment, the eosinophil count decreased dramatically, to 400/mm3, while severe abdominal pain developed. Since abdominal X-ray film revealed free air in the abdominal cavity, emergency laparotomy was performed and multiple intestinal ulcers with perforations were found. Partial ileectomy was performed. Pathological findings of the resected specimen were interpreted as a necrotizing angiitis with extravascular granuloma. Since the operation, the patient has been asymptomatic, except for neurological symptoms. Hypereosinophilia has decreased without treatment to counts averaging 270/mm3, within 3 months. On the basis of the clinical features and histopathological findings, a diagnosis of Churg-Strauss syndrome was established.

Case report: Wegener's granulomatosis accompanied by communicating hydrocephalus

A case of Wegener's granulomatosis (WG) accompanied by communicating hydrocephalus is described. An elderly woman with rapidly progressive renal failure was referred to the authors' hospital. Renal histologic study showed necrotizing granulomatous glomerulonephritis with some multinucleated giant cells, which suggested a diagnosis of WG. After admission, a gait disturbance, incontinence, and dementia developed in the patient. Diagnostic procedures including lumbar puncture, computed tomography (CT), and scintigraphy showed findings compatible with communicating hydrocephalus with a normal cerebrospinal fluid (CSF) pressure. Removal of 20 mL of CSF led to a marked improvement in symptoms. Because the presence of subarachnoid hemorrhage, meningitis, and brain tumor was excluded, the final diagnosis was communicating hydrocephalus secondary to WG.

Nomenclature of systemic vasculitides. Proposal of an international consensus conference

The following are some of the conclusions and proposals made at the Chapel Hill Consensus Conference on the Nomenclature of Systemic Vasculitis. 1. Although not a prerequisite component of the definitions, patient age is recognized as a useful discriminator between Takayasu arteritis and giant cell (temporal) arteritis. 2. The name "polyarteritis nodosa," or alternatively, the name "classic polyarteritis nodosa," is restricted to disease in which there is arteritis in medium-sized and small arteries without involvement of smaller vessels. Therefore, patients with vasculitis affecting arterioles, venules, or capillaries, including glomerular capillaries (i.e., with glomerulonephritis), are excluded from this diagnostic category. 3. The name "Wegener's granulomatosis" is restricted to patients with granulomatous inflammation. Patients with exclusively nongranulomatous small vessel vasculitis involving the upper or lower respiratory tract (e.g., alveolar capillaritis) fall into the category of microscopic polyangiitis (microscopic polyarteritis). 4. The term "hypersensitivity vasculitis" is not used. Most patients who would have been given this diagnosis fall into the category of microscopic polyangiitis (microscopic polyarteritis) or cutaneous leukocytoclastic angiitis. 5. The name "microscopic polyangiitis," or alternatively, "microscopic polyarteritis," connotes pauci-immune (i.e., few or no immune deposits) necrotizing vasculitis affecting small vessels, with or without involvement of medium-sized arteries. Cryoglobulinemic vasculitis, Henoch-Schönlein purpura, and other forms of immune complex-mediated small vessel vasculitis must be ruled out to make this diagnosis. 6. The name "cutaneous leukocytoclastic angiitis" is restricted to vasculitis in the skin without involvement of vessels in any other organ. 7. Mucocutaneous lymph node syndrome must be present to make a diagnosis of Kawasaki disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of abnormal thyroid function tests in connective tissue disease

The prevalence of thyroid function tests' abnormalities in 170 patients with various connective tissue diseases (CTD) was examined and compared to a group of 100 age- and sex-matched controls. The overall prevalence of diagnosed thyroid disease was 3.5%. Categorizing the patients into 5 "functional groups" by the concurrent thyroid function test/results showed normal thyroid function tests in 14%, isolated elevated TSH levels with normal T4 and T3 levels in 4% and findings consistent with the laboratory diagnosis of primary hypothyroidism in 3%. The "euthyroid sick syndrome" was evidenced in 54% and elevated T4 levels and/or increased or normal T3 values with normal TSH in 25%. Antimicrosomal antibodies were noted in 12 patients (7%), with the highest incidence in systemic lupus erythromatosus patients (10%). patients with mixed connective tissue disease had significantly (p < 0.0005) higher frequency of hypothyroidism, whereas patients with systemic vasculities had higher frequency of hyperthyroxinemia. In conclusion, CTD patients frequently have abnormal results of one or more of thyroid function tests. Hypothyroidism and hyperthyroidism should be considered when evaluating symptoms and signs in CTD and a significant subset of CTD patients appears to be predisposed to the development of hyperthyroidism.

[Allergic angiitis with granulomatosis: the Churg and Strauss syndrome]

Churg-Strauss Syndrome is a disorder characterized by pulmonary and systemic necrotizing vasculitis, extravascular granulomas, and eosinophilia occurring almost exclusively in patients with asthma or a history of allergy. The clinical manifestations most commonly associated with asthma are mononeuritis multiplex, gastrointestinal, cutaneous, cardiac and renal involvement. ANCA are found in 2/3 of the patients with Churg-Strauss Syndrome and are usually p-ANCA. The treatment of Churg-Strauss Syndrome relies on corticosteroids and cyclophosphamide.

[Treatment of systemic vasculitis]

Progress in the treatment of systemic vasculitis have permitted a decrease of mortality but with an increase in iatrogenic morbidity. Steroids remain the cornerstone of the treatment but precise modalities and other concomitant treatments are depending upon the type of vasculitis. In most cases, systemic vasculitis are primary and the treatment, although important, is symptomatic. However, in some cases such as hepatitis B virus-induced polyarteritis nodosa or hepatitis C virus-induced cryoglobulinemia, the treatment can be etiologic and is directed against the antigen responsible for the systemic vasculitis. In the future, a better understanding of pathological mechanisms, particularly of etiologic factors, and new treatment such as monoclonal antibodies should increase the prognosis of systemic vasculitis.

Antineutrophil cytoplasm antibodies (ANCA) of IgA isotype in adult Henoch-Schönlein purpura

ANCA are associated with certain forms of systemic vasculitis, and have been reported previously to be of the IgG and IgM isotype. We examined the possible association between IgA ANCA and the IgA-related diseases Henoch-Schönlein purpura (HSP) and IgA nephropathy (IgAN). IgA and IgG ANCA were detected by isotype-specific solid-phase assays with a crude neutrophil extract, and their presence was confirmed by antigen-specific fluid-phase competitive inhibition tests and by indirect immunofluorescence. The possible interference by IgA rheumatoid factor was excluded. IgA ANCA were detected in sera from 11/14 HSP patients (79%), from 1/30 IgAN patients (3%), from 1/40 patients with vasculitides classically associated with IgG ANCA (2.5%), and in none of 60 sera from healthy blood donors. IgG ANCA were present with IgA ANCA in three patients with HSP. Only one HSP serum had anti-myeloperoxidase (MPO) activity by both IgA and IgG isotype-specific ELISA, and none was positive for proteinase 3 (PR3). Western blot analysis performed with neutrophil extract showed that the four strongest IgA ANCA-positive HSP sera reacted with a 51-kD protein; Western blot performed on cellular fractions showed that this protein is primarily membrane-associated, and different from fibronectin. Our study suggests that adult HSP is closely associated with circulating IgA ANCA, which may be directed against a different autoantigen than that recognized by IgG ANCA.

Fatal vertebral giant cell arteritis

Death due to giant cell arteritis (GCA) is rare, and is usually caused by coronary or vertebral arteritis in the acute phase of the disease. A case of fatal GCA is reported in a woman with a normal erythrocyte sedimentation rate, who had been treated for temporal arteritis for eight months. Post mortem examination showed a dissection and thrombosis of the intracranial portion of the left vertebral artery caused by giant cell arteritis. Focal coronary artery GCA was also found. As far as is known, this is the only case in which dissection of the vertebral artery attributable to GCA has been reported.

Ocular presentation of polyarteritis nodosa. Clinical course and management with steroid and cytotoxic therapy

BACKGROUND

Polyarteritis nodosa is a necrotizing vasculitis affecting medium and small-sized arteries throughout the body, including ocular tissues. Untreated polyarteritis nodosa carries a very poor prognosis. Treatment with steroids increases the 5-year survival to 48%, whereas addition of cytotoxic immunosuppressive treatment improves the outcome dramatically.

METHODS

The authors reviewed five cases of polyarteritis nodosa with a spectrum of ocular findings which preceded and contributed to its diagnosis.

RESULTS

The ophthalmic manifestations of polyarteritis nodosa in these patients included scleritis, peripheral ulcerative keratitis, nongranulomatous uveitis, retinal vasculitis, pseudotumor of the orbit, and central retinal artery occlusion associated with temporal arteritis. In four patients, cytotoxic immunosuppressive therapy was begun promptly, and elimination of inflammation was achieved.

CONCLUSIONS

The authors' presentation of these cases is intended to emphasize the fact that ocular inflammation can be the earliest presenting manifestation of polyarteritis nodosa and that its recognition may lead to the early institution of therapy, which can decrease morbidity and mortality in this disease.

Is raised von Willebrand factor a marker of endothelial cell damage?

This hypothesis proposes that, in the absence of actively metastasising neoplasia, damage to the endothelium can be monitored by measuring circulating levels of von Willebrand factor. This specific product of the endothelial cell is important in thrombo-genesis as its functions include platelet aggregation and mediation of platelet adhesion to the subendothelium. High levels are found in all major risk factors of atherosclerosis, in frank atherosclerotic vascular disease and in most of the inflammatory vasculitides, and the highest levels are also associated with more severe disease and risk of mortality. It follows that high levels of von Willebrand factor may be a new risk factor for the development of thrombosis and atherosclerosis.

Wegener's granulomatosis with peripheral eosinophilia. Atypical variant of a classic disease

A patient with Wegener's granulomatosis (WG) diagnosed by ultrasound-guided transthoracic biopsy of a pulmonary nodule is reported. The case is atypical because of marked eosinophilia in the peripheral blood and the pleural effusion. The granulomatous infiltrate of the lung showed the classic picture of WG without eosinophils. The patient responded dramatically to treatment with steroids and cyclophosphamide. This variant form of WG poses problems in its distinction from Churg-Strauss syndrome, and the differential diagnosis between these two entities is discussed.

Circulating intercellular adhesion molecules-1 and autoantibodies including anti-endothelial cell, anti-cardiolipin, and anti-neutrophil cytoplasma antibodies in patients with vasculitis

Circulating intercellular adhesion molecule-1 (ICAM-1) and 3 types of autoantibodies were measured in 30 patients with angiographical or pathological proved vasculitis. There were 18 patients with systemic vasculitis and 12 patients with cutaneous vasculitis. The measured antibodies included anti-endothelial cell antibodies (AECA), anti-cardiolipin (ACL) antibodies of 3 isotypes and anti-neutrophil cytoplasma antibodies (ANCA). The results showed that patients with systemic vasculitis had elevated levels of ICAM-1, AECA and IgG isotype antibody as compared with none or lower in patients with cutaneous vasculitis. Levels of ICAM-1 and IgG isotype ACL antibodies also decreased significantly after disease activity subsided in patients with systemic vasculitis. Measurement of ICAM-1 and autoantibodies may be useful in evaluating the extent of involvement and in following the disease activity of patients with vasculitis.

Chronic inflammatory meningoencephalitis should not be mistaken for Alzheimer's disease

We describe two patients with a chronic encephalopathy that clinically resembled dementia but that resolved after oral administration of high-dose corticosteroid therapy. Both patients had serologically documented Sjögren's syndrome, a diagnosis that was further supported by biopsy of a salivary gland in one. Neither patient had radiologic evidence of vasculitis of the central nervous system. In one patient, meningeal and brain biopsy specimens showed perivascular inflammatory lymphocytic infiltrates. Chronic inflammatory meningoencephalitis is a treatable cause of chronic encephalopathy that should be clinically distinguished from dementia associated with Alzheimer's disease.

Inflammatory ulcers

A large number of diseases can eventuate in cutaneous ulceration. This article will review inflammatory disorders which by their nature can directly produce cutaneous breakdown and ulcer formation. Major emphasis is given to those disorders where recent knowledge has improved our understanding of the condition or where new therapeutic agents or maneuvers have become available. This later group consists of vasculitis, disorders caused by small vessel thrombi or embolus and pyoderma gangrenosum.

Panuveitis and multifocal retinitis in a patient with leucocytoclastic vasculitis

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Erythema elevatum diutinum associated with Wegener's granulomatosis and IgA paraproteinemia

A 69-year-old man had erythema elevatum diutinum for several years before he developed IgA paraproteinemia and a limited form of Wegener's granulomatosis. This is the first report of an association between erythema elevatum diutinum and Wegener's granulomatosis. IgA paraproteinemia has been reported in association with erythema elevatum diutinum but not with Wegener's granulomatosis.

Genetic selection for crescent formation yields mouse strain with rapidly progressive glomerulonephritis and small vessel vasculitis

We have established a recombinant inbred strain of mouse named spontaneous crescentic glomerulonephritis-forming mouse/Kinjoh or SCG/Kj. Mice of this strain spontaneously develop rapidly progressive glomerulonephritis. This strain of mice was derived from (BXSB/Mp x MRL/Mp-lpr/lpr)F1 hybrid mice by brother x sister mating coupled with repeated histopathologic selection for breeding of mice whose parents had the highest frequency of crescent formation in the kidneys. In this strain of mice, nephritis appears earlier and is more rapidly progressive than in any other murine model of systemic lupus erythematosus. Histopathologically, the characteristic renal lesions in the mice of this strain express a most dramatic form of crescentic glomerulonephritis. The lesions in the kidneys show only slight fine granular immune deposits along the glomerular basement membrane associated with remarkable extraglomerular proliferation and hemorrhage in Bowman's space. Although selection was not based on vasculitis, mice of this strain also exhibit a high incidence of necrotizing vasculitis. These vascular lesions involve primarily small arteries and arterioles and many organs and tissues but spare the kidneys. Thus this form of vasculitis has been found to be correlated with the crescentic form of glomerulonephritis but not with lymphoid hyperplasia of the spleen. We conclude that, in this strain of mouse, the rapidly progressive glomerulonephritis is genetically restricted and that this genetic restriction is firmly linked to that responsible for the vasculitis.

Relapsing polychondritis presenting as cutaneous polyarteritis nodosa

Relapsing polychondritis is an infrequently diagnosed, though not necessarily uncommon, systemic disorder characterized by recurrent and potentially destructive inflammation of cartilaginous structures, the eye, and the audiovestibular and cardiovascular systems. Although dermal involvement occurs in approximately 25% of patients with relapsing polychondritis, in only few cases has a skin biopsy been obtained revealing lesions such as leukocytoclastic vasculitis, livedo reticularis, erythema nodosum or keratodermia blenorrhagicum. We describe a patient with relapsing polychondritis in whom a cutaneous polyarteritis nodosa preceded cartilage inflammation by 6 months. Cutaneous polyarteritis nodosa is a rare form of vasculitis that appears to be limited primarily to the skin, muscles, and joints. In contrast to the systemic form of the disease it is characterized by the absence of visceral lesions and a relapsing but benign course. The present case and the fact that vasculitis is a concomitant feature in approximately 30% of patients with relapsing polychondritis [21] demonstrates that this condition may not represent a distinct clinical entity.

Serum markers of T cell activation in relapses of Wegener's granulomatosis

Levels of soluble IL-2 receptor (sIL-2R), soluble CD4 (sCD4) and CD8 (sCD8) were measured by sandwich ELISA as markers for T cell activation in serial serum samples from 16 patients showing 18 histologically proven relapses of Wegener's granulomatosis (WG). Levels of sIL-2R increased from 1065 U/ml (median, range 373-2345 U/ml) 6 months before the relapse to 1684 U/ml (median, range 486-3404 U/ml) at the moment of relapse for the whole group (P = 0.10). The eight major relapses showed a profound rise in sIL-2R levels, from 1008 U/ml (median, range 686-1553 U/ml) 6 months before the relapse, to 1994 U/ml (median, range 1469-3404 U/ml) at the moment of relapse (P < 0.01). The levels of sIL-2R at the moment of relapse were significantly higher at the eight major relapses than at the time of the 10 minor relapses (P < 0.05). Minor relapses were not accompanied by a significant rise in sIL-2R levels. Titres of antineutrophil cytoplasmic antibodies (ANCA) rose by two or more titresteps or from negative to positive in 15/18 patients during the 6 months period before the relapse. In all seven cases with both a rise of the ANCA titre and an at least 25% increase in sIL-2R levels, the rise in ANCA preceded the rise in sIL-2R by at least 1 month. The level of sIL-2R at the moment of relapse correlated with the level of C-reactive protein (r = 0.488, P < 0.05) and with the disease activity score (r = 0.824, P < 0.002). There were no significant changes in levels of sCD4 or sCD8, although the levels of sCD4 tended to be higher at the time of major relapses. We conclude that major relapses of Wegener's granulomatosis are accompanied by systemic T cell activation. T cell activation, however, does not appear to precede the rise in ANCA titre.

Identification of haptoglobin as an angiogenic factor in sera from patients with systemic vasculitis

Angiogenesis is an important process in chronic inflammatory diseases. We observed that sera from patients with systemic vasculitis stimulated angiogenesis in an in vitro model using human umbilical vein endothelial cells cultured on a basement membrane (Matrigel) substrate. After 40% ammonium sulfate precipitation, angiogenic activity remained in the low molecular weight fraction and could be inactivated by heat. SDS-page of serum FPLC fractions exhibiting maximal angiogenic activity demonstrated two prominent species of 45 and 16-20 kD in patients' sera. These bands were much less apparent in sera obtained from control subjects. Amino-terminal sequencing of the 45-kD protein demonstrated that it was haptoglobin. Purified haptoglobin stimulated angiogenesis in a dose-dependent manner. The angiogenic activity of vasculitis patients' sera was partially inhibited by an antihaptoglobin antibody. Furthermore, serum haptoglobin levels in vasculitis patients correlated both with disease and angiogenic activity. Haptoglobin angiogenic activity was confirmed in two in vivo models using an implanted disc and a subcutaneous injection of basement membrane. Stimulation of angiogenesis is a newly recognized biological function of haptoglobin. The increased levels of haptoglobin found in chronic inflammatory conditions may play an important role in tissue repair. In systemic vasculitis, haptoglobin might also compensate for ischemia by promoting development of collateral vessels.

Anti-lymphocyte antibodies and circulating immune complexes in the sera of patients with myelopathy associated with human T lymphotropic virus type-I

We measured levels of circulating immune complexes in the human T-lymphotropic virus type I (HTLV-I)-associated myelopathy (HAM) by Raji cell assay and C1q binding assay using an enzyme-linked immunosorbent assay (ELISA). The levels of anti-lymphocyte antibody were also measured using normal donor peripheral blood T-lymphocytes. The levels of anti-lymphocyte antibodies were significantly higher in the sera of patients with HAM compared to controls (P < 0.01). The concentrations of immune complexes measured by Raji cell assay were also significantly higher in the HAM patients' sera than in controls. However, when levels of immune complexes were measured by C1q binding assay, there was no significant difference between HAM patients and controls. There was no significant difference in the levels of anti-lymphocyte antibodies and immune complexes between HTLV-I carriers and controls. Circulating immune complexes detected by the Raji cell assay did not include HTLV-I p-19 as detected by the indirect immunofluorescent method. Levels of anti-lymphocyte antibody were correlated with levels of circulating immune complexes as detected by the Raji cell assay in the sera of patients with HAM. These findings indicate that anti-lymphocyte antibodies and circulating immune complexes are present in the sera of HAM patients, and that the levels of complexes detected by Raji cell assay may reflect anti-lymphocyte antibody levels.

Serum markers of T-cell activation in relapses of Wegener's granulomatosis

Levels of soluble IL-2 receptor (sIL-2R), soluble CD4 (sCD4) and CD8 (sCD8) were measured by sandwich ELISA as markers for T-cell activation in serial serum samples drawn monthly from 16 patients showing 18 histologically proven relapses of Wegener's granulomatosis (WG). Levels of sIL-2R increased from 1162 U/ml (median, 95% CI 843 to 1814 U/ml) at three months before the relapse to 1684 U/ml (95% CI 1254 to 2202 U/ml) at the time of relapse for the whole group (P = 0.10). The 8 major relapses showed a profound rise in sIL-2R levels (P < 0.01). The level of sIL-2R at the moment of relapse correlated with the level of C-reactive protein (r = 0.547, P < 0.05) and with the disease activity score (r = 0.814, P < 0.001). There were no significant changes in levels of sCD4 or sCD8.

The secretion of the third component of complement (C3) by human polymorphonuclear leucocytes from both normal and systemic lupus erythematosus cases

Recently, murine peritoneal exudate polymorphonuclear leucocytes (PMNs) have been proved to secrete complement C3. In this report we show the secretion of C3 by normal human blood PMNs. ELISA assay was used to detect secreted C3 in culture supernatants of PMNs, while immunoperoxidase staining was used for intracellular C3 detection. 12-o-tetradecanoyl phorbol 13 acetate (TPA) had a flushing effect on C3 secretion by PMNs but not macrophages, suggesting a special C3 storing capability in PMNs. Dioctanoyl glycerol, mezerein and calcium ionophore A23187 caused the same marked increase in C3 secretion by PMNs. This suggests the contribution of protein kinase C and the calmodulin pathway in the mechanism of C3 secretion, similar to murine peritoneal exudate PMNs. In some cases of systemic lupus erythematosus, C3 secretion by blood PMNs was increased but no similar response to TPA could be detected.

Classification of vasculitis

A working classification of necrotizing vasculitis based on size of the affected vessel is proposed. The classification proposed by Gilliam and Fink in 1976 is a basis for the current proposal. A revised working classification of vasculitis is presented. Small vessel necrotizing vasculitis and larger vessel necrotizing vasculitis categories are further subdivided. Improved understanding of the basic science aspects of vasculitis will hopefully give rise to a better consensus on the classification of vasculitis.

Anti-neutrophil cytoplasm antibodies, anti-GBM antibodies and anti-dsDNA antibodies in glomerulonephritis

The diagnostic potential of assays detecting anti-neutrophil cytoplasm antibodies (ANCA), anti-GBM antibodies and anti-dsDNA antibodies was evaluated by examining sera from time of admission in a consecutive series of 455 patients with biopsy verified primary or secondary glomerulonephritis (GN). ANCA were classified into c- and p-ANCA by indirect immunofluorescence (IIF) and ELISAs using alfa-granule extract, proteinase-3, myeloperoxidase (MPO), elastase and lactoferrin. C-ANCA was virtually confined to 64 patients with systemic small vessel vasculitis, 66-74% being c-ANCA positive. P-ANCA against MPO, seen in 47 patients, segregated through many diagnostic categories of primary and secondary severe GN. ANCA against lactoferrin and elastase were rare. Anti-dsDNA positive patients constituted 57% of the 44 ANA-positive patients with systemic lupus erythematosus. It is concluded that the IIF and ELISAs for anti-proteinase-3, anti-MPO, anti-dsDNA and anti-GBM have an acceptable performance and are useful in the primary diagnostic work-up of patients suspected for secondary GN as the majority of such patients will be classified by these assays.

Pulmonary vascular involvement in sarcoidosis: a report of 40 autopsy cases

We examined pulmonary vascular involvement in 40 autopsy cases of sarcoidosis. In these cases granulomatous involvement was observed at all levels from large elastic pulmonary arteries to venules, and venous involvement was more prominent than arterial involvement. The extent of granulomatous vascular involvement was related to that of parenchymal granuloma. No significant difference was found between upper and lower lobes in the incidence of granulomatous vascular involvement. The distribution of granulomata in the blood vessels was segmental and adventitial, and medial involvement was prominent in the larger vessels. Healed lesions of granulomatous vascular involvement also were observed at various levels in blood vessels. Prominent granulomatous involvement was found in the lymphatic capillaries and collecting lymphatic vessels in lungs with sarcoidosis. Serial sections of the lungs demonstrated interstitial granuloma directly connecting the lymphatic capillaries around small blood vessels. Granulomatous involvement in vasa vasorum and lymphatic capillaries is likely to be an important factor in the pathogenesis of granulomatous vascular involvement in lungs with sarcoidosis. The present study suggests that granulomatous vascular involvement and its sequelae may contribute to the development of pulmonary sarcoidosis.

Propylthiouracil-induced hypersensitivity vasculitis presenting as respiratory failure

Hypersensitivity vasculitis associated with propylthiouracil therapy is a well-documented clinical entity. Although any organ system may be involved, it is most unusual for pulmonary manifestations to be the cardinal presenting features. We report a 72-year-old woman presenting with respiratory failure and hemoptysis following initiation of propylthiouracil therapy for Graves' disease. She had cutaneous stigmata of hypersensitivity vasculitis and diffuse pulmonary infiltrates. The infiltrates improved dramatically after discontinuation of the propylthiouracil therapy and initiation of intravenous corticosteroid therapy.

Pulse cyclophosphamide therapy in Wegener's granulomatosis: a pilot study

Five patients with Wegener's granulomatosis (WG) have been treated with 6- to 8-monthly pulses of intravenous cyclophosphamide (CP) and glucocorticoids in an open pilot study. One patient achieved complete remission sustained during 30 months of follow-up; one patient had features of active disease after 28 months of remission; two patients after an initial remission had an exacerbation of the disease and received continuous oral administration of CP, and one patient required continuous oral CP to control the symptoms. These results suggest that this regimen may not achieve a high degree of sustained remission in patients with WG.

Cranial nerve involvement in childhood polyarteritis nodosa

Amongst a variety of neurological manifestations of childhood polyarteritis nodosa, cranial nerve involvement is unusual. We report 4 cases with cranial nerve palsies in a series of 36 biopsy-proven patients. Two cases presented with IIIrd nerve palsy alone, one with right IIIrd and left IVth nerve palsy, and one with peripheral VIIth nerve paresis. All 4 patients showed good response to prednisolone and cyclophosphamide treatment. Cranial nerve involvement in childhood polyarteritis nodosa seems not so rare when patients are followed on long term basis.

The use of corticosteroids in dermatological practice

OBJECTIVE

To discuss the various uses of corticosteroids in patients with skin diseases.

DATA SOURCES

All relevant literature published since 1950 was reviewed and 33 studies were selected.

CONCLUSIONS

Systemic and topical corticosteroid preparations are used commonly in patients with skin diseases. Oral administration of steroids is particularly useful in acute hypersensitivity diseases, connective tissue diseases, immunological blistering diseases, and the commoner dermatoses when they are very severe and widespread. Topical steroid preparations are mainly used in the different forms of dermatitis, but are also useful in psoriasis and a number of other skin diseases. If potent topical steroid preparations are used for too long, or in excessive quantities, side effects will be encountered as a direct effect on the skin, for example atrophy, and as a result of systemic absorption, for example, hypothalamic-pituitary-adrenal suppression and Cushing's syndrome.

Short term effects of intravenous pulses of cyclophosphamide in the treatment of connective tissue disease crisis

A predominantly outpatient regimen of low dose intravenous cyclophosphamide was used to treat patients with serious progressive connective tissue diseases. Fifty five patients were treated with a total of 211 intravenous pulses of cyclophosphamide. Forty five patients had previously shown no response to a variety of other treatments. Low dose intravenous cyclophosphamide (500 mg) was given in 179 pulses and repeated pulses were given in most patients at weekly intervals for one to three weeks to induce disease remission. A good response was noted in 37 of 55 (67%) patients assessed four weeks after the pulses. Only 20 patients needed more than one such course of three pulses of intravenous cyclophosphamide during the observation period. The non-responders were characterised by longstanding disease and irreversible histological findings in renal and muscle biopsy samples. Patients with vasculitis, notably Wegener's granulomatosis, showed the most immediate response, and in most patients the amount of corticosteroids required was markedly reduced. In some patients steroids were completely stopped during the follow up period. The most striking observation of this effective but more conservative regimen was the low incidence of major side effects such as neutropenia and infections. It is concluded that low dose pulses of intravenous cyclophosphamide are well tolerated and are an effective treatment for patients with aggressive connective tissue diseases.