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

Induction of remission in a patient with Takayasu's arteritis by low dose pulses of methotrexate

A 42 year old woman with Takayasu's arteritis responded to treatment with prednisone (60 mg daily) but developed severe side effects. Cyclophosphamide treatment did not produce a clinical improvement or steroid sparing effect. A treatment trial with a weekly pulse of low dose methotrexate improved her symptoms and the patency of her occluded left subclavian artery.

Antibodies to endothelial cells in primary vasculitides mediate in vitro endothelial cytotoxicity in the presence of normal peripheral blood mononuclear cells

Twenty-eight out of 62 patients with Wegener's granulomatosis and micropolyarteritis display circulating antiendothelial cell antibodies (AECA) detectable by a cell surface radioimmunoassay. These antibodies do not induce an in vitro endothelial damage either alone or in the presence of fresh complement; however, 50% of IgG-AECA positive sera can be cytotoxic in the presence of human normal peripheral blood mononuclear cells (PBM) at high effector/target ratios. The specificity of the PBM-mediated cytotoxicity is supported by the absence of the phenomenon in AECA negative sera, by the disappearance of the lytic effect after absorption of AECA, and by the finding that cellular-mediated cytotoxicity can be reproduced by purified IgG-AECA positive fractions. On the contrary, polymorphonuclear leukocytes or adherent mononuclear cells are not involved in such a cytotoxic activity. AECA seem to be directed against determinants consitutively expressed on the endothelial surface since the activation of endothelial cells by interleukin-1 beta or interferon-gamma affects neither the antibody binding nor their ability to mediate 51Cr release in the presence of PBM. These findings favor the hypothesis for a possible direct pathogenetic role of circulating AECA in the in vivo vascular damage.

AAEM minimonograph #38: neuropathies in connective tissue disease

Neuropathies are common in patients with known or suspected connective tissue disease. A vasculitic mononeuropathy multiplex is often seen in patients initially presenting with polyarteritis nodosa or developing arteritis as a complication of rheumatoid arthritis. However, vasculitic neuropathy may become confluent and present as as distal symmetrical polyneuropathy or occur without systemic necrotizing vasculitis. Distal symmetrical polyneuropathies without associated vasculitis are also common in many connective tissue diseases. Compression neuropathies, especially carpal tunnel syndrome, occur with increased frequency in rheumatoid arthritis. Finally, certain neuropathies may be the major presenting feature of particular connective tissue diseases. For example, trigeminal neuropathy often heralds the onset of systemic sclerosis or mixed connective tissue disease, and sensory neuronopathy may be the initial presenting feature of Sjögren's syndrome.

HLA class II specificities in vasculitis with antibodies to neutrophil cytoplasmic antigens

HLA class II genes were examined in patients with small vessel vasculitis associated with anti-neutrophil cytoplasmic antibodies (ANCA) using restriction fragment length polymorphism and allele specific oligonucleotide typing. Fifty-nine patients were studied, 34 with Wegener's granulomatosis and 25 with microscopic polyarteritis, and their results were compared with those from 1103 British Caucasoid controls. The frequency of HLA-DQw7 was significantly increased in patients with vasculitis (patients 53%; controls 27.8%, chi 2 17.8, Pc less than 0.0025, relative risk 2.9), and all the DQw7 bearing haplotypes commonly found in Caucasoid populations contributed to the increase. By contrast, the frequency of HLA-DR3 bearing haplotypes was decreased in the patients (patients 6.8%; controls 21.6%, chi 2 6.7, P less than 0.01). HLA specificities were similar in the groups of patients presenting with Wegener's granulomatosis and microscopic polyarteritis and with different types of ANCA assessed by indirect immunofluorescence. However, patients with the DQw7, DR4 haplotype were significantly more likely to have transiently positive tests for ANCA than patients with other DQw7 bearing haplotypes, whereas patients with DR2 bearing haplotypes were more likely to have persistently positive ANCA. These results show that HLA class II genes are associated with small vessel vasculitis and may influence the duration of the associated autoimmune response.

Cerebral occlusive vasculopathy in systemic lupus erythematosus and speculation on the part played by complement

A 35 year old woman with systemic lupus erythematosus and hypocomplementenaemia presented with new onset seizures and subsequently died. At necropsy, widespread microinfarctions of the cerebral cortex were found to be predominantly due to the formation of leucoaggregates within small blood vessels without any vasculitis.

Vasculitis and pyrexia associated with superficial spreading gastric carcinoma

A case of low-grade fever developing about a month before the discovery of gastric carcinoma is reported. No findings of infection or collagen disease were revealed. The fever continued for about 3 months, but promptly disappeared after surgical removal of the tumor. A superficial spreading mucosal carcinoma with minimal invasion to the submucosa was seen in the antrum, showing the features of poorly differentiated adenocarcinoma. In addition, unique venous inflammation was recognized beneath and around the neoplasm. Arteries and lymph vessels did not exhibit any inflammatory changes. It was presumed that the gastric carcinoma had induced phlebitis, which subsequently brought about the fever. As to the pathogenetic mechanism, it was suggested that a substance produced by the carcinoma cells flowed into nearby veins to induce the phlebitis.

Systemic diseases affecting the mesenteric circulation

The mesenteric circulation is acutely sensitive to processes that affect the entire body. Such systemic diseases and syndromes are reviewed with particular emphasis on the mechanisms by which they influence the mesenteric vasculature and blood flow.

Immune deposits in iris biopsy specimens from patients with Fuchs' heterochromic iridocyclitis

To investigate whether Fuchs' heterochromic iridocyclitis may be an immune complex vasculitis, we used an immunofluorescence technique to detect immunoglobulins and complement in iris biopsy specimens from nine patients with Fuchs' heterochromic iridocyclitis, 12 patients with other types of uveitis, and nine patients with glaucoma but without uveitis. No specific immune deposits were observed in the irises of the patients with Fuchs' heterochromic iridocyclitis. Immunoglobulin G, IgA, IgM, and complement were detected in patients with Fuchs' heterochromic iridocyclitis and patients with uveitis, and these results differed significantly (P less than .05) from the group without uveitis. The immune deposits were found only in the iris vessel walls. No light-microscopic evidence of an inflammatory vascular process could be detected. Further studies are necessary to investigate whether the immune reactants originate from the circulation or result from local formation.

Vancomycin and teicoplanin: something old, something new

OBJECTIVE

To compare and contrast the pharmacology, activity and clinical efficacy of two glycopeptide antibiotics, vancomycin and teicoplanin.

DATA SOURCES

English language literature search using MEDLINE, Index Medicus, relevant textbooks and product information literature.

STUDY SELECTION

Over 200 publications were examined extending back to the period of initial Phase I trials with vancomycin.

DATA EXTRACTION AND SYNTHESIS

Many publications covered similar ground and came to the same conclusions. In these instances one or two of the best pieces were chosen as cited reference material. Conflicting results and conclusions are discussed and an attempt is made to interpret the findings.

CONCLUSION

Vancomycin and teicoplanin show differences in activity both in vitro and in vivo. Vancomycin is superior against coagulase-negative staphylococci and reliable dosage regimens are available. Teicoplanin, however, needs to be given in significantly larger doses than initially thought necessary to maximise clinical efficacy. Teicoplanin has a lower incidence of side effects but in clinical practice this advantage is small. Vancomycin remains the glycopeptide of choice for the treatment of infections due to Gram-positive bacteria.

Endothelial cell activation in vasculitis of peripheral nerve and skeletal muscle

To clarify the role of endothelial cells in the pathogenesis of vasculitis affecting peripheral nerve and skeletal muscle, the endothelial expression of adhesion molecules and major histocompatibility antigens (MHC) in different vasculitic syndromes were studied, and related to the presence of anti-endothelial cell antibodies (AECA). Increased expression of the intercellular adhesion molecule ICAM-1 in vasculitic lesions in nerve and muscle was shown, and this was associated with increased expression of MHC class I and II antigens. AECA were detected in low titre in only a minority of patients. The findings suggest that endothelial cells have a critical role in mediating the tissue injury in vasculitis affecting nerve and muscle and that the process is triggered by cellular and not antibody-mediated mechanism in the majority of patients.

Fundamental and clinical aspects of anti neutrophil cytoplasmic antibodies (ANCA)

Anti-neutrophil cytoplasmic antibodies (ANCA) are associated with different forms of both primary and secondary vasculitis and glomerulonephritis. These antibodies are directed against different enzymes located in granulocyte granules. In this review ANCA-related antigens and solid phase assays for ANCA detection will be discussed. Furthermore, we will address the clinical relevance of ANCA and will deliberate on their possible pathogenic implications.

Iron pigment deposits, small vessel vasculitis, and erythrophagocytosis in the muscle of human immunodeficiency virus-infected patients

Hemosiderin deposition and vascular inflammation were evaluated in muscle specimens from 50 human immunodeficiency virus (HIV)-infected individuals with neuromuscular symptoms. Iron deposits were detected in 25 of 50 cases, and were found more frequently in the distal muscles of lower limbs than in proximal muscles (22 of 30 cases v three of 20 cases; P less than .001). The incidence was higher than in controls (P less than .01). Polyarteritis nodosa was observed in three cases and microvascular inflammation was observed in 27. Direct immunofluorescence showed deposits of both immunoglobulins (mainly immunoglobulin M) and complement in small vessel walls of 19 of 34 patients. The p17 and p24 HIV antigens were detected in three of 27 cases. Both T8 lymphocytes and macrophages were significantly more numerous in patients with Perls'-positive material; these patients also showed vascular inflammation more frequently. Other findings included noninflammatory microangiopathy (18 cases), tubuloreticular inclusions in endothelial cells (one case), and free and intracytoplasmic eosinophilic globules likely representing digested erythrocytes (seven cases). The present study shows that iron pigment deposition in skeletal muscle is a nonspecific finding, frequently observed in the lower extremities of HIV-infected individuals, where it reflects immunopathologic alterations of the microcirculation. Erythrophagocytosis, which may be observed in the muscle of some HIV-infected individuals, may also be implicated.

Necrotizing scleritis after ocular surgery. A clinicopathologic study

Necrotizing scleritis may appear after trauma to the sclera. The authors studied 10 patients in whom necrotizing scleritis developed after ocular surgery. The interval between surgery and onset of scleritis varied from 2 weeks to 6 months. Nine patients (90%) were found to have an underlying autoimmune vasculitic systemic disease, which was subsequently treated with immunosuppression. One patient was found to have a local infectious process, which was treated with antibiotics. Appropriate studies led to the discovery and subsequent treatment of a systemic disease or an infectious process in 6 of the 10 patients; the other 4 patients had been previously diagnosed. Results of immunohistochemical studies on resected conjunctival and/or sclera suggest local immune complex deposition, increased HLA-DR expression, and increased helper T-cell participation in conjunctiva and/or scleral tissues after trauma in patients with underlying systemic autoimmune vasculitic disease. The results emphasize the need for meticulous diagnostic pursuit of potentially lethal systemic autoimmune vasculitic disease in patients with necrotizing scleritis after intraocular surgery.

Plasma exchange in focal necrotizing glomerulonephritis without anti-GBM antibodies

To determine whether plasma exchange was of additional benefit in patients treated with oral immunosuppressive drugs for focal necrotizing glomerulonephritis (without anti-GBM antibodies), we performed a randomized controlled trial with stratification for renal function on entry. Forty-eight cases were analyzed, 25 in the treatment group (plasma exchange, prednisolone, cyclophosphamide and azathioprine) and 23 in the control group (drug therapy only). There was no difference in outcome in patients presenting with serum creatinine less than 500 mumol/liter (N = 17), or greater than 500 mumol/liter but not on dialysis (N = 12), all but one of whom had improved by four weeks. However, patients who were initially dialysis-dependent (N = 19) were more likely to have recovered renal function (P = 0.041) if treated with plasma exchange as well as drugs (10 of 11) rather than with drugs alone (3 of 8). Long-term follow-up showed that improvement in renal function was generally maintained. The results of this trial confirm that focal necrotizing glomerulonephritis related to systemic vasculitis responds well to immunosuppressive drugs when treatment is started early, and suggest that plasma exchange is of additional benefit in dialysis-dependent cases.

Giant cell arteritis in two Chinese patients

Giant cell arteritis is virtually unknown in Orientals. We report two cases of histologically proven giant cell arteritis in two elderly Chinese men, one of whom presented with typical symptoms and the other with occult features of the disease.

Antigen specificities and clinical distribution of ANCA in kidney diseases

The antigenic specificity and clinical distribution of the antineutrophil cytoplasmic antibodies (ANCA) in kidney diseases have recently been extensively studied. In patients with systemic vasculitis, the great predominance of two major ANCA antigens, proteinase 3 (PR3) and myeloperoxidase (MPO), is now established. PR3 and MPO are colocalized in the azurophilic granules of neutrophils and translocated to the cell surface during activation, and thus are able to interact with autoantibodies after neutrophil preactivation. Furthermore, by comparison of amino acid and DNA sequences, it has been shown that PR3 is identical to myeloblastin, which has been described independently and is involved in the control of growth and differentiation of leukemic cells. Aside from the two major ANCA antigens, a number of neutrophil cytoplasmic antigens recognized by ANCA have been identified, including human leukocyte elastase, lactoferrin, CAP57, and cathepsin G. These rare ANCA specificities occur in a limited number of patients. The variety of ANCA antigen specificities contrasts, however, with the fact that the vast majority of ANCA-positive sera are monospecific for one single ANCA antigen. With regard to clinical distribution, ANCA have major diagnostic significance in the four conditions in which they are frequently detected: Wegener's granulomatosis (WG), Churg and Strauss Syndrome (CSS), microscopic periarteritis (MPA), and necrotic and crescentic glomerulonephritis (NCGN). However, the initial dichotomy between MPO-associated vasculitis (NCGN, MPA) and that associated with anti-PR3 antibodies (WG) appears far from absolute.

Expression of monocyte chemotactic protein and interleukin-8 by cytokine-activated human vascular smooth muscle cells

The present study was designed to investigate the capacity of human vascular smooth muscle cells (SMCs) to produce a cytokine chemotactic for monocytes (monocyte chemotactic protein [MCP]) and by way of comparison, a related polypeptide activator of neutrophils (known as interleukin-8 [IL-8] or neutrophil activating protein-1 [NAP-1]. On exposure to IL-1, SMCs released high levels of chemotactic activity for monocytes, which could be removed by absorption with anti-MCP antibodies. MCP production by activated SMCs was comparable to that of IL-1-stimulated umbilical vein endothelial cells. Activated SMCs released appreciable levels of IL-8, as determined by a specific enzyme-linked immunosorbent assay, but little chemotactic activity for neutrophils. IL-1-treated SMCs expressed high levels of both MCP and IL-8 mRNA transcripts, as assessed by Northern blot analysis. Tumor necrosis factor and bacterial lipopolysaccharide but not IL-6 also induced MCP and IL-8 gene expression in SMCs. Nuclear runoff analysis revealed that IL-1 augmented transcription of the MCP and IL-8 genes. The capacity of SMCs to produce a cytokine (MCP) that recruits and activates circulating mononuclear phagocytes may be of considerable importance in the pathogenesis of vascular diseases (e.g., vasculitis and atherosclerosis) that are characterized by monocyte infiltration of the vessel wall.

Unusual patterns of serum antibodies to Streptococcus equi in two horses with purpura hemorrhagica

An enzyme-linked immunosorbent assay (ELISA) was developed for use in horses to determine serum titers of antibodies of the immunoglobulin classes IgA, IgG, and IgM to Streptococcus equi M-like protein and culture supernatant protein antigens. Serum antibodies were determined in 28 adult horses, including 9 horses with recent S. equi infections, 17 horses without known exposure to S. equi, but without a history of respiratory disease in the preceding 4 months, and 2 horses with clinical purpura hemorrhagica. Serum IgA titers to culture supernatant protein antigen were highest in recently infected horses (P less than 0.001). Serial determinations of antibody titers in the horses with purpura showed that IgG antibodies to both S. equi M-like protein and culture supernatant protein antigens were undetectable initially, but later rose coincidental with clinical recovery from the disease. Possible mechanisms for these findings are discussed.

Pulmonary vascular involvement in sarcoidosis: granulomatous angiitis and microangiopathy in transbronchial lung biopsies

To evaluate the occurrence of granulomatous angiitis and microangiopathy in the lung with sarcoidosis, transbronchial lung biopsy specimens were examined from 174 cases with sarcoidosis. Granulomatous angiitis was seen in 72 cases, which corresponded to 53% of the cases with granulomata. Granulomatous angiitis showed venous involvement (65%), both venous and arterial involvement (24%) or arterial involvement only (11%). There was no significant difference in occurrence of granulomatous angiitis between upper and lower lobes. The cases with granulomatous angiitis in the lung had a higher frequency of ophthalmic symptoms and elevated serum angiotensin converting enzyme level. Basal lamina layering in the microvasculature was more often observed in the bronchial mucosa than in the alveolar walls and is not exclusively related to granulomata. Endothelial proliferation and basal lamina alterations in granulomatous angiitis may be closely associated with granulomas. The present study revealed coexistence of granulomatous angiitis and microangiopathy in the lung with sarcoidosis and suggests that both may participate in the development of pulmonary sarcoidosis.

Antineutrophil cytoplasmic antibody--a useful serological marker for vasculitis

Systemic necrotizing vasculitides, including polyarteritis nodosa, Churg-Strauss syndrome, "overlap" systemic vasculitis, Wegener's granulomatosis, and idiopathic crescentic glomerulonephritis, are frequent clinical diagnostic problems. These diseases have diverse presentations and are often rapidly progressive, causing irreversible injury to the vessels of the kidneys and lungs before effective immunosuppressive therapy is instituted. Even in their less fulminant forms, they are a cause of significant morbidity and mortality. Antineutrophil cytoplasmic antibody, a recently identified autoantibody, has a high sensitivity and specificity for this spectrum of diseases. The clinical and pathological similarities, the high frequency of antineutrophil cytoplasmic antibody expression, and the similar good response to immunosuppressive therapy suggest that these diseases may be linked by a common pathophysiological mechanisms. Evidence is growing that antineutrophil cytoplasmic antibody plays a central role in this mechanisms. A revision in the classification scheme of vasculitides to recognize that the polyarteritis group (polyarteritis nodosa, Churg-Strauss syndrome, and "overlap" systemic vasculitis), Wegener's granulomatosis, and idiopathic crescentic glomerulonephritis are closely related diseases may be warranted. The clinical and pathological features of systemic necrotizing vasculitides and the current knowledge concerning antineutrophil cytoplasmic antibodies are reviewed.

Detection of autoantibodies against myeloid lysosomal enzymes: a useful adjunct to classification of patients with biopsy-proven necrotizing arteritis

PURPOSE

Assessment of the value of determination of antineutrophil cytoplasmic antibodies (ANCA) and its specificities for classification of patients with biopsy-proven necrotizing arteritis.

PATIENTS AND METHODS

The serum samples of 28 consecutive patients with biopsy-proven vasculitis involving medium- and/or small-sized arteries were tested for ANCA by an indirect immunofluorescence technique, by neutrophil extract enzyme-linked immunosorbent assay (ELISA), and by catching ELISA.

RESULTS

Eight patients had Churg-Strauss syndrome; six had myeloperoxidase (MPO) antibodies, and in the other two patients, ANCA were not detected. Six patients had polyarteritis nodosa (PAN) limited to the skin and the musculoskeletal system; ANCA were not detected in these patients. Two patients had systemic PAN and both had MPO antibodies. The remaining 12 patients had overlapping clinical features of the different forms of vasculitis. Five patients had polyarteritis in combination with chronic nasal inflammation and glomerulonephritis compatible with Wegener's granulomatosis (WG) but without granulomas in the respiratory tract. All five patients had 29-kd serine protease antibodies. Two patients had polyarteritis in combination with nasal polyposis and asthma compatible with Churg-Strauss syndrome, but eosinophilia was not detected. Both patients had MPO antibodies. Three patients with unclassified granulomatous arteritis had either elastase antibodies or ANCA of unknown specificity. One patient with unclassified systemic vasculitis had 29-kd serine protease antibodies, and one patient with necrotizing arteritis of the bowel in combination with Schönlein-Henoch purpura was negative for ANCA.

CONCLUSION

Determination of ANCA and its specificities is a useful adjunct to the classification of patients with biopsy-proven necrotizing arteritis. Within the spectrum of idiopathic vasculitides, 29-kd serine protease antibodies are associated with WG, MPO antibodies are associated with Churg-Strauss syndrome and systemic PAN, and PAN limited to the skin and the musculoskeletal system is not associated with ANCA.

Treatment of systemic vasculitis with pooled intravenous immunoglobulin

The therapeutic effect of a course of high-dose, pooled, intravenous immunoglobulin (IVIg) on disease activity and circulating antineutrophil cytoplasm antibodies (ANCA) was investigated in 7 patients with systemic vasculitis. 5 had active disease despite conventional immunosuppression, and 2 had not received any treatment. All 7 had clinical improvement, which was sustained in 6 and transient in 1. The fall in ANCA concentrations to a mean of 51% of the pre-treatment values was maintained during follow-up. C-reactive protein concentration also dropped considerably. IVIg seemed to confer a useful therapeutic effect without adverse reaction.

Diagnostic significance of hypocomplementemia

Hypocomplementemia is an important marker for the presence of IC-mediated disease and can be used to assess disease activity. However, in interpreting the clinical significance of hypocomplementemia, the following must be kept in mind: 1) There are numerous non-immunologic conditions that also can cause hypocomplementemia. Furthermore, some of these conditions can cause a multisystem disease that, along with the hypocomplementemia, can closely resemble an IC-mediated systemic vasculitis. Furthermore, these nonimmunologic conditions that lower serum complement levels can complicate the course of patients with inactive IC-mediated disease, spuriously indicating that the disease is active. The most relevant of these differential diagnostic problems are listed in Table 2. 2) There are a few conditions (for example, pregnancy) that can raise serum complement levels, thereby possibly obscuring the presence of a disorder (such as, active SLE) that is lowering complement levels. 3) There are some conditions that might be expected to lower serum complement levels, because of their effect on protein metabolism, but do not. Nephrotic syndrome, and moderately poor nutrition are examples. All of these factors should be considered when interpreting results of serum complement levels in a given patient.

Circulating anti-entactin antibodies in patients with glomerulonephritis

Sera from 305 consecutive patients in a renal biopsy series were analyzed for the presence of anti-entactin antibodies by ELISA. Of these patients, 59% had primary glomerulonephritis, 21% had secondary glomerulonephritis, while 20% had other nephropathies (noninflammatory conditions like amyloidosis, diabetic nephropathy, nephrosclerosis, etc.). Forty-one of these patients (13.4%) were positive for IgG/IgM antibodies against entactin: 60% of them had primary glomerulonephritis, 35% had secondary glomerulonephritis, while the remaining 3 patients had other nephropathies. Fifteen (70%) of the 23 patients with primary glomerulonephritis had proliferative glomerulonephritis (PGN), whereas 13 (87%) of the 15 patients with secondary glomerulonephritis were due to systemic connective tissue diseases (SCTD): 7 due to SLE, 4 due to SLE like SCTD and two due to other SCTD. There was a peak of incidence corresponding to the group aged 18 to 30 years. A majority of these patients (12 of the total 17) had primary glomerulonephritis and were associated with nephrotic or subnephrotic grade proteinuria, poorly or nonresponsive to immunosuppressive treatment and associated, in several cases, with progressive deterioration of renal function. In addition, there was a tendency to another peak in the age group 51 to 60 years. Most of these patients (6 of the total 8) had glomerulonephritis secondary, mainly, to SLE or SLE like SCTD with milder degree of proteinuria and better preserved renal functions. Anti-entactin antibodies were not found in certain glomerulonephritides like IgA nephropathy and those secondary to systemic vasculitides and in control subjects (healthy subjects, and patients with a variety of non-renal disorders including inflammatory diseases).(ABSTRACT TRUNCATED AT 250 WORDS)

Neurologic manifestations of Schönlein-Henoch purpura

The presence of a possible cerebral involvement in Schönlein-Henoch Purpura was investigated in a prospective study comprising 26 children. A hampering headache accompanied by behavioural changes was present in 8 patients (31%). No cases of seizures, aphasia, ataxia, pareses or cerebral haemorrhage were found. EEG-abnormalities like slow wave foci, sharp waves, and paroxysms were demonstrated in 12 patients (46%) during the acute phase of the disease. The EEG-changes were transient but persisted in 4 patients during a follow-up period lasting one year. A significant association was found between the presence of headache and an abnormal EEG-tracing.

[Clinical study and diagnostic criteria of periarteritis nodosa. Apropos of 27 cases]

Periarteritis nodosa is a necrotizing vasculitis diagnosed on clinical, angiographic and histological criteria. We conducted a retrospective study of the various clinical and paraclinical manifestations of the disease in a series of 27 patients hospitalized in an Internal Medicine department. Visceral angiography showed microaneurysms in only 12.5% of the cases, and we consider that the indications of this method are limited. Segmental necrotizing vasculitis of the medium- and small-caliber arteries was found in only 33% of muscle biopsies. This criterion has low sensitivity and must be improved by systematic electromyography which showed abnormal results in 87% of the patients. Due to the insufficient sensitivity of paraclinical criteria, the clinical criteria proposed by Godeau and Guillevin are of great practical value. However, we suggest that their definition should be modified on three points: multineuritis should be replaced by peripheral neuropathies; livedo should be included in the cutaneous criterion, and positive serology for hepatitis B or C virus should be added to the positivity criteria.

Immunosuppressive drugs in immune and inflammatory ocular disease

Advances in immunology, particularly ocular immunology, have been accompanied by the emergence of safer, more specific immunosuppressive drugs, notably, cyclophosphamide, chlorambucil, methotrexate, azathioprine, cyclosporine A, bromocriptine, dapsone, and colchicine. These drugs have become an important, and often essential, part of the ophthalmologist's armamentarium against inflammatory and immune-mediated ocular diseases. In order to better acquaint the ophthalmologist with the properties of the most commonly used immunosuppressive drugs, we review the literature and relate our own experience with these agents.

Albendazole versus praziquantel in the treatment of cerebral cysticercosis: clinical evaluation

One hundred consecutive patients presenting with symptoms and signs of neurocysticercosis, confirmed by neuroimaging techniques, were randomly assigned to treatment with either praziquantel 50 mg/kg/d for 15 d or albendazole 15 mg/kg/d for 30 d. All patients were treated in addition with steroids for 45 d. Follow-up was for 90 d for response to treatment and at least 1 year for recurrence. Although similar numbers of patients showed no improvement in neuroimaging criteria at 3 months, the response to albendazole was more pronounced with larger numbers showing marked improvement or disappearance of lesions. Resolution of the presenting neurological signs and symptoms was also more frequent in the albendazole group. Electroencephalographic changes also became normal. The use of steroid cover eliminated the headache frequently present during the first few days of treatment and permitted severe cases to be treated. Both albendazole and praziquantel appeared to be effective at the doses used, with albendazole showing a slightly better overall response.

Late-onset congenital syphilis. A retrospective look at University of Iowa Hospital admissions

A retrospective review of 766,742 hospital admissions was performed between 1966 and 1986 at the University of Iowa Hospital for the diagnosis of congenital syphilis. Although 88 individuals were identified with this diagnosis, adequate treatment was documented in only 33 (38%). Thirty-nine of the 88 individuals identified were initially seen for visual complaints by the ophthalmology department. We recommend that all physicians increase their index of suspicion for this disease, and institute appropriate therapy and follow-up if late congenital syphilis is diagnosed.

[Antineutrophil cytoplasmic antibodies: a new diagnostic tool]

Two main types of antineutrophil cytoplasmic antibodies (ANCA) have been recognized by indirect immunofluorescence. ANCA-D are defined by diffuse fluorescence and are directed against proteinase 3. They are highly specific for Wegener's granulomatosis, and their titre varies with disease activity. ANCA-P are responsible for perinuclear fluorescence and are principally found in other types of vasculitis and in idiopathic crescentic glomerulonephritis. In patients with suggestive clinical signs, ANCA are of considerable diagnostic value when specific histology is difficult to obtain. Therapeutic monitoring and prevention of Wegener's disease relapses could rely on regular measurements of ANCA titres. Moreover, studies on the pathogenetic role of ANCA may transform current physiopathological concepts and nosology of vasculitis.

A rare cause of splenic infarct and fleeting pulmonary infiltrates: polyarteritis nodosa

A rare multi-system disease with an incidence of about 5/million per year, polyarteritis nodosa (PAN) occasionally may cause splenic vasculitis, usually at arteriole bifurcations, leading to multiple systemic infarcts with extensive confluent systemic necrosis. PAN may also be a cause of fleeting patchy pulmonary infiltrates or pulmonary nodular lesions. The diagnosis is usually difficult and delayed because the clinical manifestations are varied and depend on the site and the extent of the arterial involvement.

Vascular toxicity in dogs associated with overdoses of a novel benzodiazepine receptor partial agonist

Necrotizing arteritis and periarteritis were found in Beagle and German Shepherd dogs treated for 13 or 52 weeks with the novel benzodiazepine receptor (BZR) partial agonist Ro 16-6028 (generic name bretazenil). Eight male and one female out of a total of 20 dogs treated with 40-60 mg/kg/day Ro 16-6028 developed the arteritis, predominantly in the heart or the epididymis. Two of these animals died prematurely following treatment at the initial dosing levels of 80 and 55 mg/kg/day; one of these two dogs was asymptomatic and in good general condition until death. Clinically, all but one of the dogs showed sedation, ataxia, stiff gait, body weight-loss and a deterioration of the general condition as well as changes of some laboratory parameters. No signs of arteritis and untoward clinical or laboratory findings were seen at lower doses. Possible aetiologies, as well as the mechanisms involved in arteritis in general and the genetic disposition of beagles in particular for this type of effect, are discussed. Reflections on the potential risk to man of this so far unknown finding after oral treatment with 1,4-benzodiazepines (BZs) are presented.

Subarachnoid haemorrhage in Wegener's granulomatosis, with negative four vessel angiography

Two patients with Wegener's granulomatosis and spontaneous subarachnoid haemorrhage are presented in whom four vessel angiograms were normal. The diagnosis of Wegener's granulomatosis should be considered in patients with subarachnoid haemorrhage and negative four vessel angiography. The presence of antibodies to a neutrophil cytoplasmic antigen may be of diagnostic value.

Vasculitis of peripheral nerve and skeletal muscle: clinicopathological correlation and immunopathic mechanisms

In order to elucidate the pathogenesis of vasculitis in muscle and nerve a clinicopathological study was performed in 23 patients. The patients could be classified into three groups: I multisystem vasculitis (n = 4); II multisystem disease with vasculitis detectable in nerve, muscle, or both (n = 11); and III localised disease with vasculitis in nerve, muscle, or both (n = 8). Ten of 23 patients had vasculitis in both muscle and nerve biopsies; 6 from groups I and II, and 4 from group III indicating that vasculitis confined to muscle and nerve represents a distinct clinicopathological entity. The neuromuscular manifestations in the 23 patients were sensori-motor polyneuropathy (n = 9), mononeuritis multiplex (n = 6), mononeuropathy (n = 3), proximal myopathy (n = 4), and muscle tenderness without weakness (n = 1). Sensori-motor polyneuropathy was found in 8/11 patients from group II, and mononeuritis multiplex in 5/8 patients from group III. Immunotypic analysis, and immunofluorescence patterns indicate that the pathogenesis of vasculitis in muscle and nerve is heterogeneous and suggest that cell mediated and immune complex mechanisms predominate and may be operative in all three patient groups, with an antibody-mediated humoral mechanism in some patients with paraproteinaemic states (group II).