Corneal autoimmunity in a patient with relapsing polychondritis

Autoimmunity and Autoinflammation: Relapsing Polychondritis and VEXAS Syndrome Challenge

Relapsing polychondritis is a chronic autoimmune inflammatory condition characterized by recurrent episodes of inflammation at the level of cartilaginous structures and tissues rich in proteoglycans. The pathogenesis of the disease is complex and still incompletely elucidated. The data support the important role of a particular genetic predisposition, with HLA-DR4 being considered an allele that confers a major risk of disease occurrence. Environmental factors, mechanical, chemical or infectious, act as triggers in the development of clinical manifestations, causing the degradation of proteins and the release of cryptic cartilage antigens. Both humoral and cellular immunity play essential roles in the occurrence and perpetuation of autoimmunity and inflammation. Autoantibodies anti-type II, IX and XI collagens, anti-matrilin-1 and anti-COMPs (cartilage oligomeric matrix proteins) have been highlighted in increased titers, being correlated with disease activity and considered prognostic factors. Innate immunity cells, neutrophils, monocytes, macrophages, natural killer lymphocytes and eosinophils have been found in the perichondrium and cartilage, together with activated antigen-presenting cells, C3 deposits and immunoglobulins. Also, T cells play a decisive role in the pathogenesis of the disease, with relapsing polychondritis being considered a TH1-mediated condition. Thus, increased secretions of interferon γ, interleukin (IL)-12 and IL-2 have been highlighted. The "inflammatory storm" formed by a complex network of pro-inflammatory cytokines and chemokines actively modulates the recruitment and infiltration of various cells, with cartilage being a source of antigens. Along with RP, VEXAS syndrome, another systemic autoimmune disease with genetic determinism, has an etiopathogenesis that is still incompletely known, and it involves the activation of the innate immune system through different pathways and the appearance of the cytokine storm. The clinical manifestations of VEXAS syndrome include an inflammatory phenotype often similar to that of RP, which raises diagnostic problems. The management of RP and VEXAS syndrome includes common immunosuppressive therapies whose main goal is to control systemic inflammatory manifestations. The objective of this paper is to detail the main etiopathogenetic mechanisms of a rare disease, summarizing the latest data and presenting the distinct features of these mechanisms.

Multimodal Imaging Report of Crystalline Keratopathy in Relapsing Polychondritis

PURPOSE

To describe a case of bilateral multifocal stromal crystalline keratopathy in the setting of relapsing polychondritis (RP).

METHODS

Case report.

RESULTS

We describe a 31-year-old woman who presented with ocular inflammation, bilateral auricular chondritis, and nasal chondritis, meeting the clinical criteria of RP. We illustrate her auricular cartilaginous abnormalities, saddle nose deformity, scleritis, and discrete mid-stromal opacities in both corneas that extend through the central cornea. Uniquely, her opacities feature a marked crystalline component as demonstrated on photography, anterior segment optical coherence tomography, and confocal microscopy.

CONCLUSION

A central keratopathy is not typically reported in patients with RP. In this case report, we describe a unique diffuse bilateral nummular mid-stromal crystalline keratitis that extends into the central cornea and further define it using multimodal imaging.

Unique circumferential peripheral keratitis in relapsing polychondritis: A case report

RATIONALE

Relapsing polychondritis (RP) is a rare collagen disease characterized by inflammation and destruction of cartilage throughout the body. The paper details the clinical course of a case of RP with unique circumferential peripheral keratitis.

PATIENT CONCERNS

A 54-year-old Japanese woman was referred to the hospital presenting with auricular and ocular pain.

DIAGNOSES

Based on the auricle biopsy results and the three presenting symptoms (bilateral auricular chondritis, inflammatory arthritis and ocular inflammation), her condition was diagnosed as RP.

INTERVENTIONS

The three presenting symptoms gradually improved with prednisolone (PSL), methylprednisolone and cyclophosphamide combination therapy, followed by PSL, methotrexate and infliximab combination therapy. However, one month after the initial visit, despite ongoing treatment, a unique circumferential peripheral keratitis suddenly occurred, in which the corneal infiltration gradually clumped together and shrank at the peripheral area. The eye and ear pain showed exacerbations and remissions on reducing the dosage of steroid drugs. The general condition was improved on altering systemic therapy to PSL, methotrexate and tocilizumab.

OUTCOMES

Keratitis gradually disappeared within 10 months of the initial visit.

LESSONS

This is the first report of a case of RP causing unique circumferential peripheral keratitis. This keratitis occurred despite use of focal and systemic steroids and showed improvement with general recovery. This may indicate that stabilization of general condition is important for recovery from keratitis in RP.

Combined anterior chamber washout, amniotic membrane transplantation, and topical use of corticosteroids for severe peripheral ulcerative keratitis

PURPOSE

The aim of this study was to evaluate the efficacy of anterior chamber washout, amniotic membrane transplantation, and topical use of corticosteroids in the treatment of severe peripheral ulcerative keratitis with membranous endothelial exudation.

METHODS

Twelve patients (12 eyes) with severe corneal ulceration were included. All ulcers were located at the corneal periphery, accompanied by central corneal epithelial defects and stromal edema. Membranous endothelial exudates were observed by anterior segment optical coherence tomography. The duration of the ulcers was 1 to 10 months (mean, 3.0 ± 2.9 months) before the patients visited our institution. Corneal inflammation and ulceration could not be controlled after 2 weeks of topical antiinflammation treatment. Bacterial, fungal, and Acanthamoeba infections were not detected. Surgical treatment was performed. After the necrotic corneal tissue was cut, exudation clinging to the endothelium was removed. Then, amniotic membrane was placed on the corneal lesion. Postoperatively, corticosteroid eye drops and topical and systemic antiinflammation medication were given. Healing of corneal ulcers and improvement of stromal edema were detected by slit-lamp microscopy. All patients were followed up for 3 to 15 months (mean, 6.5 ± 3.7 months).

RESULTS

All corneal ulcers healed by 1 to 2 weeks after surgery. The corneal stromal edema subsided within 1 month. All patients achieved a stable ocular surface. There was no recurrence during the follow-up.

CONCLUSIONS

Anterior chamber washout and amniotic membrane transplantation combined with topical corticosteroids seems to be effective for the treatment of severe peripheral ulcerative keratitis with endothelial exudates.

Diagnosis and classification of relapsing polychondritis

Relapsing polychondritis is a rare and potentially fatal autoimmune disease of unknown etiology, characterized by inflammation and destruction of different cartilaginous structures, including the ear, nose, larynx, trachea, bronchi, peripheral joints, eye, heart and skin, with high risk of misdiagnosis. The spectrum of clinical presentations is protean and may vary from intermittent episodes of painful and disfiguring auricular and nasal chondritis or polyarthritis to severe progressive multi-organ damage. A laryngotracheobronchial involvement appears in nearly half of patients and is complicated by local obstructions, which may be life-threatening. A highly medical specialized approach is required for diagnosis of relapsing polychondritis. This review comprehensively examines the literature related to the clinical sceneries of the disease and focuses on both diagnostic tools used in clinical studies and recent findings related to its etiopathogenesis.

Pathogenesis of relapsing polychondritis: a 2013 update

Relapsing polychondritis (RP) is a systemic inflammatory disease primarily affecting not only the cartilaginous structures of the ears, nose and tracheobronchial tree but also the joints, the inner ear, the eyes, and the cardiovascular system. RP is an immune-mediated disease during which target antigens are still unknown, but data from human studies and murine models strongly support a role of both Collagen Type II (CII) and matrilin-1 as potential candidates. RP is likely a Th1-mediated disease as serum levels of interferon (IFN)-γ, interleukin [IL]-12, and IL-2 parallel changes in disease activity, while the levels of Th2 cytokines do not. Serum levels of sTREM-1, interferon-γ, CCL4, vascular endothelial growth factor, and matrix metalloproteinases-3 are significantly higher in RP patients than in healthy donors, with sTREM-1 correlating with disease activity. Patients with active RP also have significantly higher levels of MCP-1, MIP-1β, MIF, and IL-8 than controls. These pro-inflammatory chemokines are involved in the modulation and recruitment of monocytes and neutrophils. Altogether, these data suggest that a complex cytokine network orchestrates the recruitment of infiltrating cells in RP lesions. Cytokine modulation using TNFα blockers, rituximab, anakinra, tocilizumab, and abatacept has recently been shown effective in some RP cases but further data are needed. Better understanding of the repertoire of infiltrating cells may provide interesting clues to further define the putative RP auto-antigens. Study of circulating mononuclear cells during RP flares may also provide crucial information about the ongoing cellular trafficking and recruitment processes involved in this rare disease.

Relapsing polychondritis: a rare disease with varying symptoms

PURPOSE

Relapsing polychondritis (RPC) is a rare systemic disease affecting primarily cartilaginous and proteoglycan-rich structures. It is a potentially fatal disease with unknown aetiology. There are no specific tests for RPC. The diagnosis is dependent on clinical criteria, which include chondritis of both auricles, non-erosive inflammatory polyarthritis, nasal chondritis, ocular inflammation, respiratory tract chondritis and cochlear and/or vestibular damage. Ocular symptoms will occur in approximately 60% of RPC patients. As an example, a patient with signs of RPC is described.

METHODS/RESULT

A 30-year-old woman was referred to our department for evaluation of a central corneal ulcer in the left eye. She had a history of recurrent pain in both her auricles and was also found to have a nasal septum perforation. Relapsing polychondritis was suspected.

CONCLUSION

Non-healing corneal ulcers should alert the ophthalmologist to look for unusual reasons for this condition. RPC is one possible cause.

Relapsing polychondritis: a clinical review

OBJECTIVE

This study comprehensively reviews the literature related to relapsing polychondritis (RP).

METHODS

A detailed search via MEDLINE (PubMed) was performed using relapsing polychondritis as the key term. Relevant articles were analyzed with a focus on history, epidemiology, etiology, pathogenesis, clinical manifestations, diagnosis, treatment, and prognosis of RP.

RESULTS

RP is a rare episodic and progressive inflammatory disease of presumed autoimmune etiology first described in 1923. RP affects cartilage in multiple organs, such as the ear, nose, larynx, trachea, bronchi, and joints. In addition, it can affect proteoglycan-rich tissues, such as the eyes, aorta, heart, and skin. The diagnosis of RP is based on the presence of clinical criteria. A standardized therapeutic protocol for RP has not been established. Nonsteroidal anti-inflammatory drugs, dapsone and/or colchicine, may control disease activity in some patients. In other patients, immunosuppressive drugs and prednisone have been effective. RP is a potentially lethal disease; pulmonary infection, systemic vasculitis, airway collapse, and renal failure are the most common causes of death. Earlier studies indicate survival rates between 70% at 4 years and 55% at 10 years. In a recent study, a survival rate of 94% at 8 years may be due to improved medical and surgical management.

CONCLUSIONS

RP is a rare, multisystemic, and potentially fatal disease. The pathogenesis and optimal therapeutic approach to patients with RP is poorly understood.

Twenty-five-year panorama of corneal immunology: emerging concepts in the immunopathogenesis of microbial keratitis, peripheral ulcerative keratitis, and corneal transplant rejection

PURPOSE

To describe the most recent advances in our understanding of the cellular and molecular mechanisms involved in the immunopathogenesis of corneal immunoinflammatory disorders including microbial keratitis, peripheral ulcerative keratitis. and allograft rejection.

METHODS

Review of the published peer-reviewed literature that has contributed significantly to our modern understanding of corneal immunology. In addition, the authors have summarized the information in conceptual diagrams that highlight the critical cellular and molecular pathways that lead to corneal immune responses in the two most thoroughly studied corneal immune disorders, herpes simplex keratitis (HSK) and transplant rejection.

RESULTS

In spite of the wide array of molecular and cellular factors that mediate corneal immunity, critical mechanistic facets are shared by the various corneal immunoinflammatory disorders. These include activation and migration of local antigen-presenting cells (APCs), including Langerhans cells (LCs), upregulation in pleiotropic proinflammatory cytokines such as interleukin-1 (IL-1) and tumor necrosis factor-alfa (TNF-alpha) that can mediate a wide array of immune functions in addition to up-regulating protease expression. and chemokines that play a critical role on the one hand in attracting nonantigen-specific inflammatory cells such as neutrophils and on the other in attracting CD4+ T helper type 1 (Th1) cells that mediate most of the destruction in the cornea.

CONCLUSIONS

In the last 25 years, we have seen our field develop from a descriptive stage into a new phase where the fundamental processes that mediate and effect corneal immunity are being accurately deciphered. It is anticipated that this new knowledge will allow development of specific molecular and genetic therapeutic strategies that could target critical steps in the immunopathogenesis of disease without the untoward side-effects of nonspecific generalized immune suppression that still remains the standard of care today.