A young woman with systemic lupus erythematosus and extensive mesenteric vasculitis involving small and medium vessels

Spectrum of Large and Medium Vessel Vasculitis in Adults: Primary Vasculitides, Arthritides, Connective Tissue, and Fibroinflammatory Diseases

Purpose of Review

To provide a comprehensive overview of the spectrum of large and medium vessel vasculitis in adults with primary vasculitides, arthritides, connective tissue, and fibroinflammatory diseases as well as vasculitis mimics, for an efficient differential diagnosis and initial diagnostic approach.

Recent Findings

Imaging has had a tremendous impact on the diagnosis of medium to large vessel vasculitis, now often replacing histopathologic confirmation and identifying new disease manifestations (e.g., intracranial disease in giant cell arteritis; vascular manifestations of IgG4-related disease). Novel diseases or syndromes involving blood vessels have been described (e.g., VEXAS-Syndrome with polychondritis). The use of the terms “medium” or “large” vessel varies considerably between medical specialties.

Summary

The differential diagnosis of large and medium vessel vasculitis is becoming increasingly complex as new entities or disease manifestations of known inflammatory rheumatic diseases are regularly identified. A more precise and widely recognized definition of the vessel sizes would make future research more comparable.

Aneurysms of the superior mesenteric artery and its branches

OBJECTIVE

Aneurysms of the superior mesenteric artery (SMA) and its branches are rare and account for only 6-15% of all visceral artery aneurysms. We present our 30-year experience with management of aneurysms of the SMA and its branches at a high-volume referral center.

METHODS

A retrospective review of all patients diagnosed with an aneurysm of the SMA or one of its branches from 1988 to 2018 was performed. Pseudoaneurysms and mycotic aneurysms were excluded. Clinical presentation, etiology, aneurysm shape and size, treatment modalities and outcomes were analyzed. Growth rate of aneurysms was estimated using linear regression.

RESULTS

131 patients with 144 aneurysms were reviewed. Patients were primarily male (64%) with a median age of 60. There were 57 fusiform, 30 saccular and 57 dissection-associated aneurysms. 41 patients had an isolated SMA branch aneurysm. Degenerative aneurysms were the most common etiology (66%). 35 patients (27%) were symptomatic at presentation. 111 aneurysms had multiple computed tomography angiograms (CTA) with a median follow-up of 43.6 months (IQR 10.6-87.2 months). Only 18 aneurysms (16%) had an estimated growth rate of ≥1.0 mm per year. Initial aneurysm size was significantly associated with growth rate for fusiform aneurysms (OR 1.13 [95% CI 1.0-1.3], P = 0.02) but not saccular (OR 0.91 [95% CI 0.76-1.1], P = 1.1) or dissection-associated aneurysms (OR 1.2 [95% CI 0.91-1.5], P = 0.20). Acute abdominal pain (OR 5.9 [95% CI 1.6-22]; P = 0.01) and chronic abdominal pain (OR 3.7 [95% CI 1.1-13]; P = 0.04) were associated with aneurysm growth. There were only two ruptures, both of whom had diagnoses of fibromuscular dysplasia and systemic lupus erythematosus, respectively, whom presented as rupture with no prior imaging. 46 patients (34%) underwent operative repair with an average aneurysm size of 24.0 ± 8.6 mm, including 36 open revascularizations and 8 endovascular procedures. There was one perioperative death and nine patients had perioperative complications (25%). There were 91 aneurysms <20 mm with an average size of 13.4 ± 3.1 mm followed over a median of 120.8 months (IQR 30.5-232.2 months), and there were no ruptures within this cohort during the follow-up period.

CONCLUSION

This study represents one of the largest series on aneurysms of the SMA and its branches. Aneurysms of the SMA are relatively stable. Patients with symptomatic and fusiform aneurysms have a higher risk of growth. Aneurysms <20 mm of degenerative etiology may be safely monitored without treatment.

Gastrointestinal vasculitis due to systemic lupus erythematosus treated with rituximab: a case report

Background

Patients with systemic lupus erythematosus may present with variable gastrointestinal manifestations including peritonitis, pancreatitis, enteritis, and vasculitis. Gastrointestinal vasculitis is one of the most devastating complications of systemic lupus erythematosus, with a mortality rate of 50% when it progresses to bowel ischemia and is complicated by hemorrhage or perforation.

Case report

A young female patient known to have systemic lupus erythematosus, lupus nephritis, and antiphospholipid antibody syndrome, on immunosuppressive treatment presented to the emergency department with acute abdominal pain and nausea. The clinical findings were first associated with an acute flare of lupus nephritis according to the assessments with active laboratory parameters. However, over a short time the abdominal pain worsened and was accompanied by peritonitis and gastrointestinal hemorrhage. The computed tomography scans demonstrated a dilated bowel and thickening of the bowel compatible with gastrointestinal vasculitis. The upper and lower gastrointestinal endoscopy supported the diagnosis of vasculitis by showing multiple ulcerative lesions along the gastrointestinal tract. The patient was successfully treated with pulse corticosteroids urgently, with a fast response to subsequent rituximab therapy without any relapses. Treatment with cyclophosphamide was not preferred because the patient had a high cumulative dose.

Conclusion

Gastrointestinal vasculitis should be a primary differential diagnosis in patients with systemic lupus erythematosus presenting with abdominal pain because of its rapid progression and high mortality. The treatment choice has been suggested as cyclophosphamide for severe cases in the literature. In this case report, a patient successfully treated with rituximab without any relapses was documented.

Chance, genetics, and the heterogeneity of disease and pathogenesis in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a remarkably complex and heterogeneous systemic autoimmune disease. Disease complexity within individuals and heterogeneity among individuals, even genetically identical individuals, is driven by stochastic execution of a complex inherited program. Genome-wide association studies (GWAS) have progressively improved understanding of which genes are most critical to the potential for SLE and provided illuminating insight about the immune mechanisms that are engaged in SLE. What initiates expression of the genetic program to cause SLE within an individual and how that program is initiated remains poorly understood. If we extrapolate from all of the different experimental mouse models for SLE, we can begin to appreciate why SLE is so heterogeneous and consequently why prediction of disease outcome is so difficult. In this review, we critically evaluate extrinsic versus intrinsic cellular functions in the clearance and elimination of cellular debris and how dysfunction in that system may promote autoimmunity to nuclear antigens. We also examine several mouse models genetically prone to SLE either because of natural inheritance or inheritance of induced mutations to illustrate how different immune mechanisms may initiate autoimmunity and affect disease pathogenesis. Finally, we describe the heterogeneity of disease manifestations in SLE and discuss the mechanisms of disease pathogenesis with emphasis on glomerulonephritis. Particular attention is given to discussion of how anti-DNA autoantibody initiates experimental lupus nephritis (LN) in mice.