1
|
Berardi E, Antonica G, Procaccio A, Marziliano D, Susca N, Leone P, Sabbà C, Racanelli V, Prete M. Cutaneous polyarteritis nodosa and pulmonary arterial hypertension: An unexpected liaison. A case report. Medicine (Baltimore) 2023; 102:e36563. [PMID: 38115264 PMCID: PMC10727645 DOI: 10.1097/md.0000000000036563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/09/2023] [Accepted: 11/20/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Cutaneous polyarteritis nodosa (cPAN) is a form of medium-sized vessel necrotizing vasculitis. It is a rare, skin-limited variant of polyarteritis nodosa, characterized by dermal and subcutaneous tissue involvement. The most common findings in cPAN include digital gangrene, livedo reticularis, and tender subcutaneous nodules. However, while limited to the skin, cPAN results in significant morbidity and mortality due to the accompanying skin ischemia and necrosis, such that patients are vulnerable to superinfection. Here, we describe a unique presentation of cPAN associated with pulmonary arterial hypertension (PAH). METHODS A 78-year-old female presented with digital ischemia and leg ulcers associated with PAH. Skin biopsy showed necrotizing fibrinoid necrosis of the small- and middle-sized vessels of the dermis. A diagnosis of cPAN and PAH was made. The patient was treated with glucocorticoids, vasodilators, and cyclophosphamide. RESULTS She died due to severe sepsis complications. CONCLUSION To date, this is the first case report describing the association between cPAN and PAH. In this case, PAH is a complication of the cutaneous vasculitides suggesting that vasculopathy could play a role in the pathophysiology of PAH. However, the underlying pathophysiological mechanisms still have to be firmly established.
Collapse
Affiliation(s)
- Elsa Berardi
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Gianfranco Antonica
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Annagrazia Procaccio
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Donatello Marziliano
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Nicola Susca
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Patrizia Leone
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Carlo Sabbà
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| | - Vito Racanelli
- Centre for Medical Sciences, University of Trento and Internal Medicine Unit, Santa Chiara Hospital, Provincial Health Care Agency (APSS), Trento, Italy
| | - Marcella Prete
- Department of Interdisciplinary Medicine, Internal Medicine Unit, “Aldo Moro” University of Bari Medical School, Bari, Italy
| |
Collapse
|
2
|
Sun C, Li X, Qian H, Liang G, Xiang R, Zhao C, Li Z, Li S, Jing K, Wang Y, Zhang H, Feng S. Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio are positively correlated with disease activity of bullous pemphigoid. Arch Dermatol Res 2023; 315:2383-2391. [PMID: 37204459 DOI: 10.1007/s00403-023-02639-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/21/2023] [Accepted: 05/09/2023] [Indexed: 05/20/2023]
Abstract
Bullous pemphigoid (BP) is a complex inflammatory process with elevated levels of autoantibodies, eosinophils, neutrophils, and various cytokines. Hematological inflammatory biomarkers can reflect inflammatory state in various diseases. Up to now, the correlations of hematological inflammatory biomarkers and disease activity of BP remain unknown. The purpose of this study was to clarify the associations between hematological inflammatory biomarkers and disease activity of BP. The levels of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), platelet-to-neutrophil ratio (PNR) and mean platelet volume (MPV) of 36 untreated BP patients and 45 age and gender matched healthy controls were detected by routine blood tests. The correlations between hematological inflammatory markers and clinical characteristics of BP were statistically analyzed. The Bullous Pemphigoid Disease Area Index (BPDAI) was used to measure disease activity of BP. The mean levels of NLR, PLR, PNR and MPV in 36 untreated BP patients were 3.9, 157.9, 45.7 and 9.4 fl, respectively. Increased NLR (p < 0.001), PLR (p < 0.01), and MPV (p < 0.001) but decreased PNR (p < 0.001) were observed in BP patients when compared with healthy controls. In BP patients, the levels of NLR were positively correlated to BPDAI Erosion/Blister Scores (p < 0.01); and the levels of NLR and PLR were both positively correlated to BPDAI without Damage Score (both p < 0.05) and BPDAI Total Score (both p < 0.05). No correlation was found in other statistical analyses between hematological inflammatory markers and clinical characteristics in BP patients involved in the present study. Therefore, NLR and PLR are positively correlated with disease activity of BP.
Collapse
Affiliation(s)
- Chao Sun
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 12 Jiang Wangmiao Street, Nanjing, 210042, Jiangsu, China
| | - Xiaoguang Li
- Department of Laboratory Medicine, Chronic Disease Research Center, Medical College, Dalian University, Dalian, China
| | - Hua Qian
- Department of Laboratory Medicine, Chronic Disease Research Center, Medical College, Dalian University, Dalian, China
| | - Guirong Liang
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 12 Jiang Wangmiao Street, Nanjing, 210042, Jiangsu, China
| | - Ruiyu Xiang
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 12 Jiang Wangmiao Street, Nanjing, 210042, Jiangsu, China
| | - Chenjing Zhao
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 12 Jiang Wangmiao Street, Nanjing, 210042, Jiangsu, China
| | - Zhiliang Li
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 12 Jiang Wangmiao Street, Nanjing, 210042, Jiangsu, China
| | - Suo Li
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 12 Jiang Wangmiao Street, Nanjing, 210042, Jiangsu, China
| | - Ke Jing
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 12 Jiang Wangmiao Street, Nanjing, 210042, Jiangsu, China
| | - Yuan Wang
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 12 Jiang Wangmiao Street, Nanjing, 210042, Jiangsu, China
| | - Hanmei Zhang
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 12 Jiang Wangmiao Street, Nanjing, 210042, Jiangsu, China
| | - Suying Feng
- Department of Dermatology, Institute of Dermatology and Hospital of Skin Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 12 Jiang Wangmiao Street, Nanjing, 210042, Jiangsu, China.
| |
Collapse
|
3
|
Roy D, Sathyanarayana VA, Nagaraju B, Rao VKR. Tofacitinib as monotherapy in cutaneous polyarteritis nodosa: a case series. Rheumatol Adv Pract 2023; 7:rkad049. [PMID: 37325248 PMCID: PMC10267297 DOI: 10.1093/rap/rkad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/10/2023] [Indexed: 06/17/2023] Open
Abstract
Objective Cutaneous polyarteritis nodosa (CPAN) is a distinct clinical entity represented by a chronic, relapsing, benign course, with rare systemic involvement. Treatment is with CSs, CYC or other conventional synthetic DMARDs (csDMARDs). In this case series, we aimed to share our varied clinical experience of successfully treating patients with CPAN, with tofacitinib in a refractory/relapsing course or as upfront monotherapy without CSs/csDMARDs. Methods We report this retrospective case series managed at our rheumatology centre in Bangalore from 2019 to 2022. Four patients identified as CPAN on biopsy were able to achieve disease-free remission with tofacitinib as part of their treatment, with no relapse on further follow-up. Our patients presented with subcutaneous nodules and cutaneous ulcers. After systemic evaluation, all the patients underwent skin biopsy, which showed fibrinoid necrosis in the vessel walls of the dermis, with a histopathological impression of CPAN. They were initially treated with a conventional approach of CSs with/without csDMARDs. On experiencing a refractory/relapsing course, tofacitinib was tried in all the patients as either CS sparing or upfront monotherapy without concomitant csDMARDs. Results Use of tofacitinib resulted in improvement of ulcers and paraesthesia and in gradual healing of skin lesions, albeit with scarring, with no further recurrence or relapse over a follow-up period of 6 months for all the patients. The therapeutic effect of tofacitinib was consistent when used either as CS sparing or as upfront monotherapy, thereby proving the drug to be a promising option that warrants larger trials in future to treat the subset of patients with established CPAN. Conclusion Tofacitinib could be used for disease-free remission as monotherapy for CPAN either upfront or as CS sparing, even without concomitant csDMARDs, in those patients who are dependent on CSs or multiple DMARDs.
Collapse
Affiliation(s)
- Debaditya Roy
- Correspondence to: Debaditya Roy, Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India. E-mail:
| | | | | | - Vijay K R Rao
- Divisha Arthritis and Medical Center, Bangalore, India
| |
Collapse
|
4
|
Micheletti RG. Treatment of cutaneous vasculitis. Front Med (Lausanne) 2022; 9:1059612. [PMID: 36465944 PMCID: PMC9716566 DOI: 10.3389/fmed.2022.1059612] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 10/28/2022] [Indexed: 02/05/2024] Open
Abstract
Cutaneous vasculitis encompasses a spectrum of disease states, with varied morphology, severity, and potential for systemic involvement. Even vasculitis which is skin-limited can have a significant quality-of-life impact, necessitating treatment. This manuscript summarizes the available evidence for management of various types of skin-limited vasculitis and provides a proposed therapeutic ladder based on published studies and expert opinion.
Collapse
Affiliation(s)
- Robert G. Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
5
|
Papachristodoulou E, Kakoullis L, Tiniakou E, Parperis K. Therapeutic options for cutaneous polyarteritis nodosa: a systematic review. Rheumatology (Oxford) 2021; 60:4039-4047. [PMID: 33944902 DOI: 10.1093/rheumatology/keab402] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/23/2021] [Accepted: 04/28/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Cutaneous polyarteritis nodosa (CPAN) is a necrotizing vasculitis of the middle-size vessels, confined to the skin. We conducted a systematic review in order to identify studies evaluating the different treatment modalities used in CPAN. METHODS This systematic review was conducted according to PRISMA guidelines, registered in PROSPERO: CRD42020222195. PubMed/Medline databases were searched from inception to December of 2020 using the terms: (Polyarteritis nodosa[Title/Abstract]) AND ((therapy[Title/Abstract]) OR (management[Title/Abstract]) OR (treatment[Title/Abstract]))' and 'Cutaneous arteritis [Title/Abstract]'. Articles evaluating pertaining to the management of CPAN in adults were eligible for inclusion. RESULTS A total of seven eligible case series with 325 unique patients were included. No study included a control population. In general, systemic corticosteroids were widely used as induction treatment. Immunosuppressive agents combined with corticosteroids were AZA, hydroxychloroquine, sulfasalazine, sulphapyridine, CYC, MTX, mycophenolate, tacrolimus, rituxima and thalidomide. Other agents utilized in the studies were dapsone, colchicine, non-steroid anti-inflammatory drugs, salicylates, warfarin and clopidogrel. In some studies, the presence of ulcerations was associated with an increased risk of relapse. CONCLUSION The evidence available regarding the management of patients with CPAN is limited at best. Further studies are needed in order to evaluate the effect of treatment on disease remission, relapses and mortality.
Collapse
Affiliation(s)
| | - Loukas Kakoullis
- Department of Medicine, University of Cyprus Medical School, Nicosia, Cyprus
| | - Eleni Tiniakou
- Department of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Konstantinos Parperis
- Department of Internal Medicine, Division of Rheumatology, University of Cyprus Medical School, Nicosia, Cyprus.,Department of Medicine, Division of Rheumatology, University of Arizona College of Medicine, Phoenix, AZ, USA
| |
Collapse
|
6
|
Sánchez-Cubías SM, Martín-Nares E, Hernández-Molina G, Hinojosa-Azaola A. Clinical Characteristics and Outcomes of Mexican Patients With Polyarteritis Nodosa: A Single-Center Study Over 40 Years. J Clin Rheumatol 2021; 27:S259-S264. [PMID: 33877782 DOI: 10.1097/rhu.0000000000001705] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
METHODS We conducted a medical records review study (1975-2018) that included patients with childhood- and adult-onset PAN. Demographics, organ involvement, phenotype, treatment, and outcomes were assessed and compared against previously published cohorts. RESULTS Thirty-one patients were included, 20 (64.5%) female, with a median age at diagnosis of 28 years (interquartile range [IQR], 16-42). Seven (23%) were classified as cutaneous; 23 (74%), systemic; and 1 (3%), progressive systemic phenotype. Eleven patients (35%) had childhood-onset PAN. Most common manifestations were musculoskeletal (71%), cutaneous (68%), constitutional (61%), peripheral neuropathy (39%), and gastrointestinal (29%). The median Birmingham Vasculitis Activity Score and Five-Factor Score at diagnosis were 9 (IQR, 4-13) and 1 (IQR, 0-1), respectively. Most patients were treated with glucocorticoids (94%). Twenty-four (80%) achieved complete and 6 (20%) partial remission at a median follow-up time of 30 months (8-192 months). The median Vasculitis Damage Index at last follow-up was 1 (IQR, 0-1). Nineteen (66%) experienced relapses. Patients with childhood-onset PAN more frequently had central nervous system and gastrointestinal involvement (36% vs 5%, p = 0.04 and 64% vs 10%, p = 0.003, respectively), microaneurysms (100% vs 38%, p = 0.02), and lower levels of C-reactive protein (0.3 vs 15.4 mg/dL, p = 0.03), compared with adult-onset PAN patients. CONCLUSIONS Our cohort of PAN patients showed predominantly a systemic phenotype. Outcomes were generally good, with most patients achieving complete remission. Childhood-onset differed from adult-onset PAN in terms of clinical and serological characteristics, whereas clinical manifestations and outcomes may be different than the ones reported in other cohorts.
Collapse
Affiliation(s)
- Susy Marcela Sánchez-Cubías
- From the Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | |
Collapse
|
7
|
Efficacy and safety of treatments in cutaneous polyarteritis nodosa: A French observational retrospective study. J Am Acad Dermatol 2021; 86:1035-1041. [PMID: 34224771 DOI: 10.1016/j.jaad.2021.06.872] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/03/2021] [Accepted: 06/23/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cutaneous polyarteritis nodosa is a form of medium-sized vessel vasculitis. Despite a disabling and prolonged course, data on treatment efficacy and safety remain scarce. OBJECTIVES We aimed to describe treatment efficacy and safety in patients with cutaneous polyarteritis nodosa. METHODS This multicenter retrospective, observational study, recorded clinical and biologic data together with treatments received. The primary outcome was the rate of complete response at month 3. Secondary outcomes assessed drug survival and safety. RESULTS We included 68 patients who received a median of 2 therapeutic lines (interquartile range, 1-3). Overall, complete response was achieved in 13 of 42 (31%) patients with colchicine, 4 of 17 (23%) with dapsone, 11 of 25 (44%) with glucocorticoids (GCs) alone, 1 of 9 (11%) with nonsteroidal anti-inflammatory drugs, 11 of 13 (84%) with GCs+azathioprine, and 7 of 15 (47%) with GCs+methotrexate. GCs+azathioprine had the best drug survival (median duration, 29.5 months; interquartile range, 19.5-36.0). Response at month 3 was decreased with peripheral neurologic involvement (odds ratio, 0.19; 95% confidence interval, 0.03-0.81; P = .04). Overall, the rate of treatment-related adverse events was 18%, which led to the discontinuation of treatment in 7% of patients. LIMITATION Retrospective study. CONCLUSION Colchicine seems to confer good benefit-risk balance in cutaneous polyarteritis nodosa without peripheral sensory neuropathy. GCs+azathioprine seem the best treatment in the event of relapse.
Collapse
|
8
|
Kasap Cuceoglu M, Sener S, Batu ED, Kaya Akca U, Demir S, Sag E, Atalay E, Balık Z, Basaran O, Bilginer Y, Ozen S. Systematic review of childhood-onset polyarteritis nodosa and DADA2. Semin Arthritis Rheum 2021; 51:559-564. [PMID: 33901990 DOI: 10.1016/j.semarthrit.2021.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Diagnosis of childhood polyarteritis nodosa (PAN) has become challenging after the definition of deficiency of adenosine deaminase 2 (DADA2). We aimed to define the differential features of pediatric PAN and DADA2 patients in our center and in the literature. METHODS The charts of pediatric PAN and DADA2 patients followed at the Pediatric Rheumatology Unit of Hacettepe University between 2010-2020 were analyzed. A systematic literature review was conducted for articles regarding pediatric PAN or DADA2. RESULTS Thirty-four pediatric PAN and 18 pediatric DADA2 patients were included. The age at onset was younger, parental consanguinity, livedo reticularis, neurologic involvement (especially strokes), lymphopenia, and hypogammaglobulinemia were more frequent, while thrombocytosis and panniculitis were less frequent in DADA2 patients. The primary treatment was anti-tumor necrosis factor (anti-TNF) in DADA2. For induction treatment, all systemic PAN patients received corticosteroids, and cyclophosphamide (n=11) or mycophenolate mofetil (MMF) (n = 3). Cyclophosphamide was replaced with MMF in nine once remission was confirmed with PVAS. In the literature, 28 articles describing 613 pediatric PAN patients and 26 articles describing 207 pediatric DADA2 patients were identified. Neurologic, gastrointestinal, and cardiac involvements were more frequent in DADA2, while constitutional symptoms and testis involvement were more common in PAN. CONCLUSION In a child with PAN-like phenotype, DADA2 should be considered in the presence of young age at disease onset, parental consanguinity, strokes, lymphopenia, and lack of thrombocytosis during active disease. Anti-TNF treatment is indicated for vasculitic DADA2. Cyclophosphamide could be switched to MMF when remission is confirmed with PVAS in severe PAN.
Collapse
Affiliation(s)
- Muserref Kasap Cuceoglu
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Seher Sener
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Ezgi Deniz Batu
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Ummusen Kaya Akca
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Selcan Demir
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Erdal Sag
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Erdal Atalay
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Zeynep Balık
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Ozge Basaran
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Yelda Bilginer
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Seza Ozen
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey.
| |
Collapse
|
9
|
Matsuda KM, Yoshizaki A, Kotani H, Kuzumi A, Fukayama M, Ebata S, Fukasawa T, Yoshizaki-Ogawa A, Sato S. Development of a prediction model of treatment response in patients with cutaneous arteritis: Insights from a cohort of 33 patients. J Dermatol 2021; 48:1021-1026. [PMID: 33768589 DOI: 10.1111/1346-8138.15868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/02/2021] [Accepted: 03/10/2021] [Indexed: 11/28/2022]
Abstract
Cutaneous arteritis (CA) is necrotizing vasculitis invading the small- to medium-sized arteries of the skin. The majority of patients can be favorably managed by low- to medium-dose systemic corticosteroids (prednisolone, <0.5 mg/kg/day) or other oral medications such as non-steroidal anti-inflammatory drugs, dapsone, and azathioprine. Meanwhile, some patients require more intensive therapy including high-dose systemic corticosteroids (prednisolone, ≥0.5 mg/kg/day), i.v. immunoglobulin, and i.v. cyclophosphamide therapy. Although predicting such treatment response among CA patients is critical in clinical decision-making, prediction rules have not yet been established. Herein, we retrospectively reviewed 33 patients regularly visiting our clinic to reveal predictive factors of their treatment response. Clinical data were collected from electronic medical records. Association between each factor and treatment response was examined by logistic regression analysis. Progression-free time was calculated by Kaplan-Meier's method and analyzed by log-rank test and Cox progression hazard model. Potential predictive factors were selected, given 1 point for each, and integrated into a classification model. Discrimination of the model was examined by the receiver operating characteristic (ROC) curve analysis. In total, 33 CA patients were enrolled in our study. Of these, 11 patients required intensive therapy, classified as treatment non-responders. Logistic analyses revealed that treatment response was significantly associated with male sex, presence of skin ulcers, and elevated serum levels of C-reactive protein at the initial work-up. Kaplan-Meier analyses also demonstrated that those factors are predictive of progression-free time. The area under the ROC curve of our classification model was 0.92 (95% confidence interval, 0.83-1.00), which classified non-responders from the others with a sensitivity of 90.9% and specificity of 81.8% at the cut-off point of 2 or more. Collectively, treatment response of CA could be predictable by a combination of sex, presence of skin ulcers, and serum levels of C-reactive protein.
Collapse
Affiliation(s)
- Kazuki Mitsuru Matsuda
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Ayumi Yoshizaki
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Hirohito Kotani
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Ai Kuzumi
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Maiko Fukayama
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Satoshi Ebata
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Takemichi Fukasawa
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Asako Yoshizaki-Ogawa
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shinichi Sato
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| |
Collapse
|
10
|
Hočevar A, Tomšič M, Perdan Pirkmajer K. Clinical Approach to Diagnosis and Therapy of Polyarteritis Nodosa. Curr Rheumatol Rep 2021; 23:14. [PMID: 33569653 DOI: 10.1007/s11926-021-00983-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE OF THE REVIEW Polyarteritis nodosa is a rare disease characterized by the necrotizing inflammation of medium-sized arteries. Different etiopathogenetic and clinical variants of the disease have been recognized over the past decades. In the present paper, we review the clinical features, diagnosis, and treatment of the different subtypes of the disease. RECENT FINDINGS The diagnosis of polyarteritis nodosa is primarily based on clinical findings, imaging, and histopathological investigations. Microbiological and genetic investigations complement the diagnostic work-up. Idiopathic and hereditary variants of polyarteritis nodosa are treated with immunomodulatory medications such as glucocorticoids, conventional immunomodulatory drugs (e.g., cyclophosphamide) and biologic agents (e.g., tumor necrosis factor inhibitors, interleukin 6 inhibitor), while hepatitis B virus-associated polyarteritis nodosa primarily requires antiviral therapy combined with plasma exchange. PAN is a disease with heterogeneous presentations, severity, and therapeutic approaches. The overall prognosis of this disease is improving, mainly due to early diagnosis and more effective treatments. Treatment choices are guided mainly by the disease subtype and severity. In this review, we have presented the current knowledge on PAN clinical variants, their classification, diagnosis, and treatment approaches.
Collapse
Affiliation(s)
- Alojzija Hočevar
- Department of Rheumatology, University Medical Centre Ljubljana, Vodnikova cesta, 62 1000, Ljubljana, Slovenia. .,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| | - Matija Tomšič
- Department of Rheumatology, University Medical Centre Ljubljana, Vodnikova cesta, 62 1000, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Katja Perdan Pirkmajer
- Department of Rheumatology, University Medical Centre Ljubljana, Vodnikova cesta, 62 1000, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
11
|
Lyakhovitsky A, Dascalu J, Drousiotis T, Barzilai A, Baum S. Hematological Inflammatory Markers in Patients with Pemphigus Vulgaris. Dermatology 2021; 237:912-920. [PMID: 33472194 DOI: 10.1159/000512916] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/10/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Emerging evidence indicates that several hematological markers can be used to evaluate treatment response, prediction, and early relapse detection in different inflammatory conditions. This study aimed to investigate the correlation between the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, platelet-to-neutrophil ratio, mean platelet volume, and disease activity in patients with pemphigus vulgaris. METHODS Fifty-six patients (20 men, 36 women; mean age 54 ± 14 years) diagnosed with pemphigus vulgaris were included in this retrospective study. Patients were divided into those treated and not treated with rituximab (groups 1 and 2), and into those who did and did not develop relapse (groups 3 and 4). The neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, platelet-to-neutrophil ratio and mean platelet volume were evaluated at the time of diagnosis, remission, and relapse. The relationship between each marker and disease stage was analyzed using the Wilcoxon rank-sum test for pairwise comparisons. RESULTS The neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio showed a positive correlation with disease activity, while the platelet-to-neutrophil ratio and mean platelet volume showed a negative correlation. The neutrophil-to-lymphocyte ratio significantly decreased in remission (p < 0.001) and significantly increased in relapse (p < 0.01). The platelet-to-lymphocyte ratio significantly decreased in remission (p < 0.001) and showed no significant change in relapse. The platelet-to-neutrophil ratio significantly increased in remission (p < 0.001) and significantly decreased at relapse (p < 0.001). The mean platelet volume significantly increased in remission (p < 0.001) and decreased non-significantly at relapse. A more significant decrease in the neutrophil-to-lymphocyte ratio in remission was found in patients not treated with rituximab. No significant differences were observed between patients who developed relapse and those who did not. CONCLUSION Our results suggest that the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, platelet-to-neutrophil ratio, and mean platelet volume can be useful markers for monitoring treatment response, while the neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio can also assist in detecting early relapse.
Collapse
Affiliation(s)
- Anna Lyakhovitsky
- Department of Dermatology, Sheba Medical Center, Tel-Hashomer, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel,
| | - Joel Dascalu
- Department of Dermatology, Sheba Medical Center, Tel-Hashomer, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Theodoulos Drousiotis
- Department of Dermatology, Sheba Medical Center, Tel-Hashomer, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Aviv Barzilai
- Department of Dermatology, Sheba Medical Center, Tel-Hashomer, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel.,Institute of Pathology, Sheba Medical Center, Tel-Hashomer, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Sharon Baum
- Department of Dermatology, Sheba Medical Center, Tel-Hashomer, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel
| |
Collapse
|
12
|
Munera-Campos M, Bielsa I, Martínez-Morillo M, Aparicio G, Olivé A, Ferrándiz C. Manifestationen, Krankheitsverlauf und prognostische Parameter bei kutaner Polyarteriitis nodosa. J Dtsch Dermatol Ges 2020; 18:1250-1260. [PMID: 33251748 DOI: 10.1111/ddg.14271_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 05/21/2020] [Indexed: 01/14/2023]
Affiliation(s)
- Mónica Munera-Campos
- Department of Dermatology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Isabel Bielsa
- Department of Dermatology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Melania Martínez-Morillo
- Department of Rheumatology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Gloria Aparicio
- Department of Dermatology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alejandro Olivé
- Department of Rheumatology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Carlos Ferrándiz
- Department of Dermatology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| |
Collapse
|
13
|
Munera‐Campos M, Bielsa I, Martínez‐Morillo M, Aparicio G, Olivé A, Ferrándiz C. Manifestations, clinical course and prognostic markers in cutaneous polyarteritis nodosa. J Dtsch Dermatol Ges 2020; 18:1250-1259. [DOI: 10.1111/ddg.14271] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 05/21/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Mónica Munera‐Campos
- Department of Dermatology Hospital Universitari Germans Trias i Pujol Universitat Autònoma de Barcelona Badalona Barcelona Spain
| | - Isabel Bielsa
- Department of Dermatology Hospital Universitari Germans Trias i Pujol Universitat Autònoma de Barcelona Badalona Barcelona Spain
| | - Melania Martínez‐Morillo
- Department of Rheumatology Hospital Universitari Germans Trias i Pujol Universitat Autònoma de Barcelona Badalona Barcelona Spain
| | - Gloria Aparicio
- Department of Dermatology Hospital Universitari Vall d’Hebron Universitat Autònoma de Barcelona Barcelona Spain
| | - Alejandro Olivé
- Department of Rheumatology Hospital Universitari Germans Trias i Pujol Universitat Autònoma de Barcelona Badalona Barcelona Spain
| | - Carlos Ferrándiz
- Department of Dermatology Hospital Universitari Germans Trias i Pujol Universitat Autònoma de Barcelona Badalona Barcelona Spain
| |
Collapse
|
14
|
Pineider J, Weon J, West L, Nanes B, Vandergriff T, Mauskar MM. Cutaneous polyarteritis nodosa with clinical features of pyoderma gangrenosum. JAAD Case Rep 2020; 6:1291-1293. [PMID: 33294567 PMCID: PMC7701038 DOI: 10.1016/j.jdcr.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - Jenny Weon
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lindsey West
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Benjamin Nanes
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Travis Vandergriff
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Melissa M Mauskar
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
15
|
Micheletti RG, Pagnoux C. Management of cutaneous vasculitis. Presse Med 2020; 49:104033. [PMID: 32645416 DOI: 10.1016/j.lpm.2020.104033] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 07/02/2020] [Indexed: 02/07/2023] Open
Abstract
Cutaneous vasculitis encompasses cutaneous components of systemic vasculitides, skin-limited variants of systemic vasculitides, such as IgA vasculitis or cutaneous polyarteritis nodosa, and single-organ cutaneous vasculitis, as individualized in 2012 in the Chapel Hill Consensus Conference Nomenclature. In this article, we focus on the management of skin-limited and single-organ vasculitides, often referred to, in clinical practice, as isolated "cutaneous leukocyctoclastic vasculitis", terms which may correspond to histological findings or descriptions, but are imprecise and not specific. Since most cases of isolated cutaneous vasculitis are self-limited and resolve spontaneously over 3 to 4 weeks, most patients require no systemic treatment. For those with severe, intractable, or chronic and recurring vasculitis, systemic therapy can be indicated and should be tailored to the severity of the disease. High-quality literature is lacking to guide management. Oral glucocorticoids may be required for a short period of time for painful, ulcerative, or otherwise severe disease in order to speed resolution. Among drugs which are reasonable longer-term options are colchicine, dapsone, azathioprine or hydroxychloroquine. Additional studies, including an ongoing multicenter randomized trial, are needed to determine the most effective therapies for skin-limited vasculitis.
Collapse
Affiliation(s)
- Robert G Micheletti
- Departments of Dermatology and Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 7 South, Room 724, Philadelphia, PA 19104, United States
| | - Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, Mount Sinai Hospital, University of Toronto, 60 Murray Street, Ste 2-220, Toronto, Ontario, M5T 3L9, Canada.
| |
Collapse
|
16
|
Shirai T, Shirota Y, Fujii H, Ishii T, Harigae H. Four distinct clinical phenotypes of vasculitis affecting medium-sized arteries. Scand J Rheumatol 2019; 48:308-314. [DOI: 10.1080/03009742.2018.1551965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- T Shirai
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Y Shirota
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - H Fujii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - T Ishii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - H Harigae
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| |
Collapse
|