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

Titration of antibodies against neutrophil cytoplasmic antigens is useful in monitoring disease activity in systemic vasculitides

Titration of antibodies against neutrophil cytoplasmic antigens (cANCA), as detected by indirect immunofluorescence, is shown to be clinically useful for monitoring disease activity in Wegener's granulomatosis and microscopic polyarteritis. Ten patients were followed (eight from presentation) prospectively for up to 2 years; during this time there were six episodes of vasculitic relapse in four patients and five infective episodes and one pulmonary embolus in four patients. Titres of cANCA were markedly raised, both at presentation (1/32-1/2048) and at vasculitic relapse (1/125-1/1048) but not in infection or embolism (negative, 1/16). Thus the titre of these antibodies can distinguish nonvasculitic illness from vasculitic relapse, in contrast to C-reactive protein levels which were raised in both. Titres of cANCA fell gradually after vasculitic relapse, in keeping with the half-life of IgG (3 weeks). C-reactive protein is a better measure of recovery.

Increased production of the third component of complement (C3) by monocytes from patients with systemic lupus erythematosus

We measured in vitro C3 production by peripheral blood monocytes from patients with systemic lupus erythematosus (SLE), and found it to be significantly greater than that from normal controls. We also found that monocytes from SLE patients with active disease produced a markedly larger amount of C3 than those from SLE patients with inactive disease. Production of C3 by monocytes correlated with serum levels of anti-dsDNA antibodies and inversely correlated with serum C3 levels in SLE patients. Serial measurement of C3 in the culture supernatant from each SLE patient showed that C3 production by monocytes fell in parallel with a decrease of disease activity. The effect of corticosteroids was ruled out as there was no relation between the level of C3 production by monocytes and the dose of prednisolone. This seems to be the first study in which the C3 production was assayed at a cellular level in SLE patients, and this study suggests that the local C3 production is increased in SLE patients.

Tubulointerstitial changes in systemic vasculitic disorders: a quantitative study of 18 biopsy cases

Tubulointerstitial alterations were studied in 18 biopsy cases of systemic vasculitis. To evaluate the changes more objectively, two indexes, the number of interstitial inflammatory cells and tubulitis percentage, were used. The group means of both of these indexes were statistically higher than those of the autopsy control group, while 14 of the cases (77.8%) showed a significant difference (P less than 0.01) between individual means and the control group means. On the other hand, tubulointerstitial changes in systemic vasculitis seemed to be less prominent than drug-induced tubulointerstitial nephritis (TIN) according to these indexes. However, comparing these indexes with those of drug-induced TIN, six cases (33.3%) of systemic angiitis could be regarded as having developed pathologic changes similar to TIN. Statistical difference was not shown in the indexes between those patients with histologic evidence of necrotizing angiitis and those without it. Clinically, urinary N-acetyl-beta-D-glucosaminidase (NAG) was abnormally high in all three examined cases, reflecting the damage of renal tubular epithelial cells. Not only the vascular and glomerular lesions, but also tubulointerstitial changes, should be evaluated in the renal biopsy specimen of systemic vasculitis.

Treatment of Wegener's granulomatosis with intermittent high-dose intravenous cyclophosphamide

PURPOSE

Concerns regarding the long-term toxicity of daily cyclophosphamide (CP) therapy for the systemic vasculitides have led us to evaluate alternative approaches to treatment in an attempt to achieve comparable efficacy with less toxicity. This study sought to determine the efficacy, toxicity, and immunologic effects of glucocorticoids (GC) and intermittent high-dose intravenous CP ("pulse" CP) in the treatment of 14 patients with Wegener's granulomatosis (WG).

PATIENTS AND METHODS

The diagnosis of active WG was supported by a typical clinical presentation and histopathologic findings of vasculitis, granulomatous inflammation, and tissue necrosis. GC treatment was initially provided on a daily basis and later tapered to an alternate-day schedule if vasculitis remained inactive. Pulse CP treatment was initially administered once a month for 6 months. If after 6 months remission had been attained and GC therapy had been discontinued, then pulse CP treatment was given at less frequent intervals thereafter. Treatment and evaluation were provided for participants as inpatients in a clinical research center (National Institutes of Health).

RESULTS

Thirteen of 14 patients (93%) initially experienced unequivocal improvement with pulse CP therapy, and seven of 14 (50%) achieved remission within 4 months. However, treatment was associated with significant toxicity in two patients and later relapses in nine patients, so that a total of 79% either failed to achieve sustained remission or were unable to continue therapy. Three of 14 (21%) patients have achieved sustained remissions with the pulse CP protocol and one additional patient (who had a limited exacerbation of WG) continues to receive that therapy after 14 to 22 months (mean 17 months).

CONCLUSIONS

The use of pulse CP and GC therapy in 14 patients with WG was associated with a high initial response rate. However, failure to respond initially to treatment, to sustain improvement, or to tolerate continued treatment was noted in 79% of patients within a period of 1 to 22 months. These observations indicate that this particular pulse CP protocol does not achieve a high degree of lasting efficacy.

Severe aortic regurgitation as a late complication of temporal arteritis

Two patients with a remote history of pathologically documented giant cell arteritis developed severe regurgitation. The first patient developed severe aortic regurgitation five years after the pathologic documentation of giant cell arteritis of the temporal arteries. Giant cell arteritis involvement of the aortic root was confirmed. The second patient developed aortic regurgitation seven years after pathologic documentation of giant cell arteries of the temporal arteries. Although pathologic confirmation of the aortic root process was not obtained, this case strengthens the clinical association between giant cell arteritis of the temporal arteries and subsequent aortic root dilatation and severe aortic regurgitation. Observation for signs of de novo severe aortic regurgitation is indicated in follow-up of patients with temporal arteritis.

The American College of Rheumatology 1990 criteria for the classification of hypersensitivity vasculitis

Criteria for the classification of hypersensitivity vasculitis were developed by comparing 93 patients who had this disease with 714 control patients with other forms of vasculitis. For the traditional format classification, 5 criteria were selected: age greater than 16 at disease onset, history of taking a medication at onset that may have been a precipitating factor, the presence of palpable purpura, the presence of maculopapular rash, and a biopsy demonstrating granulocytes around an arteriole or venule. The presence of 3 or more of these 5 criteria was associated with a sensitivity of 71.0% and a specificity of 83.9%. A classification tree was also constructed. The criteria appearing in the tree structure were the same as for the traditional format, except there were 2 pathology criteria: one required the presence of granulocytes in the wall of an arteriole or venule, and the other required the presence of eosinophils in the inflammatory exudate. The classification tree was associated with a sensitivity of 78.5% and a specificity of 78.7%.

Fibronectin degradation; an in-vitro model of neutrophil mediated endothelial cell damage

We have observed that fibronectin has a characteristic fibrillar morphology within the extracellular matrix surrounding endothelial cells. This morphology, which is easily recognizable by conventional immunoperoxidase techniques, is disrupted if neutrophils are induced to degranulate on endothelial monolayers. Loss of the fibrillar morphology (degraded fibronectin) is characterized by fragmentation and diffuse spreading of fibronectin over the surface of the endothelial cells. Loss of the normal fibronectin architecture following neutrophil degranulation is more rapid and extensive in endothelium pretreated with Interleukin-1 (IL-1). In addition, there is loss from the fibronectin molecule of a chymotryptic protease-sensitive epitope recognized by a cellular fibronectin specific antibody. Degraded fibronectin is stimulatory for neutrophils, and is likely to induce further fibronectin breakdown. This sequence has the potential to set up an amplification inflammatory loop with neutrophil mediated loss of vascular homeostasis. Alteration of fibronectin architecture is a useful marker of endothelial injury, and has important pathophysiological consequences.

Enhanced expression of the tumour necrosis factor/cachectin gene in peripheral blood mononuclear cells from patients with systemic vasculitis

The expression of tumour necrosis factor-alpha (TNF-alpha) gene in peripheral blood mononuclear cells from patients with systemic vasculitis, periarteritis nodosa and Wegener's granulomatosis, has been studied by RNA dot blot and Northern blot assays. We further examined the transcriptional level of TNF-alpha gene in peripheral blood mononuclear cells from these patients by performing nuclear run on transcription assay. We demonstrate enhanced TNF-alpha gene expression in mononuclear cells from these patients compared with healthy subjects and patients with bronchial asthma. These findings suggest that the enhanced transcription of TNF-alpha gene in peripheral blood mononuclear cells from patients with systemic vasculitis may be involved in the pathophysiology/pathogenesis of these diseases by cytokine dysregulation.

Rheumatoid arthritis and hypercoagulable state

Rheumatoid arthritis is not considered to be associated with recurrent thrombosis. We report a patient, who while receiving anticoagulants had repeated life-threatening episodes of thrombosis. She later developed severe rheumatoid arthritis. After receiving successful antiarthritic therapy and withdrawal of anticoagulants, she had no further episodes of thrombosis.

Pulmonary fibrosis as an unusual clinical manifestation of a pulmonary-renal vasculitis in elderly patients

Between 1978 and 1988, three patients at our institution had an initial diagnosis of idiopathic pulmonary fibrosis but later were correctly diagnosed as having pulmonary-renal syndrome and microscopic polyarteritis. These cases involved elderly patients with progressive dyspnea and nonproductive cough, bilateral dry crackling rales, bilateral interstitial infiltrates evident on a chest roentgenogram, and restrictive findings on pulmonary function testing. In two patients, lung biopsy specimens were obtained, and an initial diagnosis of nonspecific pulmonary fibrosis was made. All three patients eventually had microhematuria and renal insufficiency. A revised diagnosis of small-vessel pulmonary-renal vasculitis was based on the demonstration of segmental necrotizing glomerulonephritis in renal biopsy specimens in two patients, thrombotic microangiopathy consistent with healed vasculitis on postmortem examination of the kidney in one patient, and subsequent detection of small-vessel vasculitis on review of the two lung biopsy specimens. Anti-neutrophil cytoplasmic antibodies with perinuclear staining on indirect immunofluorescence microscopy were positive in the two patients in whom determinations were performed. The clinical manifestations of vasculitis were notably scarce--no involvement of the skin, nervous system, or gastrointestinal tract; no episodes of fever; and minimal or absent musculoskeletal symptoms. These cases illustrate the importance of a high index of suspicion for the diagnosis of systemic vasculitis in elderly patients and the need to consider a vasculitis in the differential diagnosis of idiopathic pulmonary fibrosis, especially if an active urinary sediment is present.

Temporal arteritis presenting as an extrapyramidal disorder

A case of temporal arteritis presenting with extrapyramidal symptoms (tremor, rigidity and extrapyramidal hypertonus) unresponsive to conventional treatment is here described. The onset of headache and laboratory abnormalities suggestive of temporal arteritis prompted a temporal artery biopsy which confirmed the diagnosis; the administration of corticosteroids led to the resolution of all symptoms.

The impact of allergy and immunology on our expanding industrial environment

In summary, allergists and clinical immunologists have assumed a primary role related to the diagnosis and pathophysiology of a wide range of environmental and occupational diseases associated with our increasingly industrialized environment. Prevention, rather than therapy, is the primary goal in managing many of these conditions. With all such diseases, it is most important to take into account the patient's environment and to record a thorough occupational and environmental history. The concept of environmental agents as causative factors of disease in man dates to antiquity but has assumed considerably greater significance in recent years. In this context, it should be remembered that Hippocrates and Socrates both emphasized that a good physician should strongly consider the patient's environment as an aid in diagnosis. Of equal importance was the recommendation by Bernardo Ramazzini in 1713, that, "in addition to the questions and recommendations of Hippocrates," a careful inquiry into the patient's occupation should be made.

Henoch-Schöenlein syndrome in Qatar: the effects of steroid therapy and paucity of renal involvement

This is a retrospective study of 40 patients admitted to Hamad General Hospital in the state of Qatar between January 1983 and December 1987 with the diagnosis of Henoch-Schöenlein syndrome. Of the 40 patients, 25 were boys and 15 were girls, with a ratio of 1.6:1. Ages ranged from 2 years 3 months to 13 years, with a mean of 6 years. There were six episodes of recurrence in four patients. There was a clustering of cases in late summer and early winter. About half of the patients had a history of preceding upper respiratory infection. All of them had the typical skin rash. The percentages of joint, gastro-intestinal and renal manifestations were 80%, 65% and 17.39%, respectively. One patient had penile swelling which has not been reported before. Steroid therapy seemed to enhance early resolution of abdominal pain but did not affect the course of the syndrome. Sixty-seven per cent of the patients were followed up for from 4 weeks to 5 years, with a mean of 8 months. Only one patient with renal involvement continued to have proteinuria with microscopic haematuria and hypertension. The rest were normal within about 2 months. The remarkably low incidence of renal involvement in our study may be related to local variations in causative factors. Henoch-Schöenlein syndrome is a milder disease in Qatar than in other countries.

Microscopic polyarteritis: a forgotten aetiology of haemoptysis and rapidly progressive glomerulonephritis

A 76 year old white woman died from massive pulmonary haemorrhage nine days after she was admitted to Parkland Memorial Hospital for evaluation of haemoptysis and rapidly progressive glomerulonephritis. The differential diagnosis of haemoptysis with rapidly progressive glomerulonephritis is presented with particular emphasis on Wegener's granulomatosis and microscopic polyarteritis. Necropsy showed a small vessel necrotising vasculitis associated with a focal segmental necrotising glomerulonephritis consistent with microscopic polyarteritis.

Rheumatologic manifestations of malignancy

The relationship between rheumatologic syndromes and cancer covers a very broad array of both common and distinctly rare manifestations. This discussion has outlined some of the known relationships that do exist. A high index of suspicion by both the primary care physician and subspecialist will enhance the probability of detecting cancer in the patient who may present with rheumatologic complaints.

Diseases of the vertebral arteries

Case reports and postmortem neuropathological findings of a wide spectrum of diseases affecting the vertebral arteries, in particular vasculitis, traumatic lesions, degenerative changes and congenital abnormalities, are discussed.

Anti-endothelial cell antibodies in patients with Wegener's granulomatosis and micropolyarteritis

Anti-endothelial cell antibodies (AECA) have been detected by cell surface radioimmunoassay in nine out of 15 patients with micropolyarteritis (MPA) and in two out of five patients with Wegener's granulomatosis. AECA mostly belonged to the IgG isotype and were present in the active phase of the diseases. These antibodies were not detectable in 10 sera from patients with essential mixed cryoglobulinaemia, suggesting that they were not a mere epiphenomenon consequent to the inflammatory vascular injury. The binding activity was not related to ABH antigens or to HLA class I antigens displayed by resting human endothelial cells in culture and was not influenced by removing immune complexes. Absorption of the anti-neutrophil cytoplasmic antibodies (ANCA), present in MPA and Wegener's granulomatosis sera, did not affect the endothelial binding. AECA-positive sera did not display lytic activity against endothelial cells, neither alone nor after addition of fresh complement or normal human peripheral blood mononuclear cells. Although AECA are not cytolytic for endothelial cell monolayers in vitro, the reactivity against intact endothelial cells suggests their possible involvement in in vivo pathological processes affecting vascular structures in small vessel primary vasculitides.

Systemic vasculitis with renal involvement--a review

Twenty five patients with renal vasculitis presenting over an eight year period were reviewed. Ten had microscopic polyarteritis, 6 classic polyarteritis, 5 overlap syndrome, 2 Churg-Strauss syndrome and 2 Wegener's granulomatosis. Clinical features included hypertension, pulmonary involvement, neurological involvement and arthralgia. Serum creatinine was over 500 umol/l in 13 patients, 10 of whom required dialysis. Visceral angiography was positive in 80% of those studied, Focal and segmental necrotising glomerulonephritis was the commonest renal lesion. Treatment consisted of corticosteroids and cytotoxic agents in most cases. Plasmapheresis was used for rapidly progressive renal failure, severe pulmonary haemorrhage or cerebral vasculitis. Improvement or stabilisation of renal function was seen in 68% of patients treated. There were 4 early deaths and one late death. The diagnosis, histology, treatment and outcome of renal vasculitis is discussed. The importance of early diagnosis and treatment is emphasised in this potentially reversible cause of acute renal failure.

Pitfalls with anti-neutrophil cytoplasmic antibodies (ANCA)

A 39-year-old Ugandan student is described presenting with general malaise, fever and a pulmonary infiltrate. Open lung biopsy showing infarction and positive ANCA lead to a diagnosis of Wegener's granulomatosis and a treatment with immunosuppressive drugs was instituted. Five weeks after admission, however, sputum cultures turned out to be positive for Mycobacterium tuberculosis. The importance of ANCA-interpretation and the possibility of false positive results is discussed.

Risk factors in idiopathic renal vasculitis and glomerulonephritis

In this retrospective study, we analyzed clinical laboratory, and pathologic variables to determine their value in predicting survival and survival free of renal failure for 170 consecutive patients with idiopathic renal vasculitis and glomerulonephritis evaluated during a 15 year period. Of the 170 patients, 108 had focal segmental necrotizing glomerulonephritis alone (FSNGN), 33 had FSNGN and small-artery vasculitis, and 29 had FSNGN and medium-sized artery vasculitis. Considerable overlap of clinical, laboratory, and pathologic findings existed among the three groups. Overall patient survival was 81% at one year, 61% at five years, and 44% at ten years, significantly less than expected survival. Overall survival free of renal failure, by definition, was lower than patient survival. There were no differences among these three groups in patient survival or survival free of renal failure. Multivariate analysis identified leukocytosis and serum creatinine level as independent predictors of patient survival and survival free of renal failure. In addition, univariate analysis identified age and hypertension as significant risk factors but did not add independent predictive value for these two end points. In patients with serum creatinine levels less than 4 mg/dl, the effect of increasing levels of leukocyte count was significantly associated with poorer outcomes for both patient survival (P = 0.006) and survival free of renal failure (P = 0.024). Outcomes for these two end points were worse for patients with lower serum creatinine levels (less than 4.0 mg/dl) and high leukocyte counts (greater than 16,000/mm3) than for those with serum creatinine levels greater than or equal to 4.0 mg/dl.

A point prevalence study of 150 patients with idiopathic retinal vasculitis: 1. Diagnostic value of ophthalmological features

This paper describes the ophthalmological features of 150 patients with idiopathic retinal vasculitis, 67 of whom had isolated retinal vasculitis (RV) and 83 had RV associated with systemic inflammatory disease (RV + SID). The diagnosis of retinal vasculitis was made by ophthalmoscopy and fluorescein angiography, and patients with any identifiable cause (infection, ischaemia, or malignancy) were excluded from the study. Patients with isolated RV tended to have peripheral vascular sheathing, macular oedema, and diffuse capillary leakage. Those with RV accompanying Behçet's disease often had branch vein retinal occlusions and retinal infiltrates together with macular oedema and diffuse capillary leakage; the retinal infiltrates were pathognomonic for Behçet's disease. In sarcoidosis the retina typically showed features of periphlebitis associated with focal vascular leakage. Patients with uveomeningitis, multiple sclerosis, arthritis, or systemic vasculitis showed diffuse retinal capillary leakage associated with a mixture of the other features. Poor visual function was particularly associated with macular oedema and branch vein retinal occlusion, while the retina appeared to 'withstand' the impact of vascular sheathing, periphlebitis, or neovascularisation alone. Within the limitations of a point prevalence study it was concluded that different patterns of retinal vasculitis occur in different systemic inflammatory diseases, and that in isolated retinal vasculitis there is a particular association between peripheral vascular sheathing, macular oedema, and diffuse capillary leakage. In Part 2 we describe the results of examining the sera of these patients for the presence of antiretinal antibodies and circulating immune complexes.

Hypersensitivity angiitis

Hypersensitivity angiitis is a disease in which patients present with palpable purpura dominant on the lower legs. As lesions evolve they become confluent, and sometimes hemorrhagic and ulcerate. Other organ systems may be involved, particularly the joints, gastrointestinal tract, and kidneys. Current evidence supports an immune complex pathogenesis in which a variety of antigens including bacteria, viruses, drugs, or chemicals are involved. Therapy consists of identifying the potential offending agent and administration of antiinflammatory drugs.

Symptomatic urogenital manifestations of polyarteritis nodosa and Churg-Strauss angiitis: analysis of 8 of 165 patients

To establish the clinical features and evolution of ureteral and testicular manifestations of polyarteritis nodosa, 8 cases among a group of 165 patients were reviewed. Urogenital manifestations are rare and were related to hepatitis B virus markers in 5 of the 8 patients. Malignant hypertension was present in 6 of 8 patients and renal insufficiency related to renal infarctions was noted in 5. Prognosis is good and regression generally is obtained with steroid therapy or with plasma exchange and vidarabine when polyarteritis is related to hepatitis B virus. In some cases ureteral stenosis may require an operation in association with steroids and/or immunosuppressive treatments.

Neurological complications of Schoenlein-Henoch syndrome: contribution of MR to the diagnosis. Case report

In the protean clinical pattern of the Schoenlein-Henoch syndrome the central and peripheral nervous system signs and symptoms are of most uncertain epidemiological importance and of most debatable physiopathological status. In the case reported the contribution of nuclear magnetic resonance to the diagnosis proved to be greater than that of computed tomography because it imaged the CNS lesions.

[Mixed cryoglobulinemia with necrotizing angiitis. Apropos of 2 cases]

Out of a series of 26 personal cases, 2 cases of mixed IgM-IgG cryoglobulinemia, one type II the other type III, are reported because they were associated with histologically proven necrotizing vasculitis. In both cases the numerous symptoms were due to renal damage (the vasculitis was discovered in the kidney) and to peripheral neuropathy. One of the patients died; the other had severely deteriorated general condition and required substitution hemodialysis. Cases of vasculitis associated with mixed cryoglobulinemia have often been published, but there are few reports mentioning necrotizing vasculitis; a search in the literature yielded only 9 cases. This small number does not mean that mixed cryoglobulinemia should not be listed among the causes of necrotizing vasculitis, but it makes it difficult to extract those specific features that would enable to predict which case of mixed cryoglobulinemia is associated or not with necrotizing vasculitis.