[S1 guidelines Diagnostics and treatment of ANCA-associated vasculitis]

[Eosinophilic granulomatosis with polyangiitis: a review article]

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of ANCA-associated vasculitis (AAV) within the group of small vessel vasculitides. It is defined by vasculitis of small and medium-sized vessels with granulomatous inflammation and blood and tissue eosinophilia. Almost all patients have allergic symptoms with bronchial asthma and rhinosinusitis symptoms. Further clinical manifestations vary depending on the localisation, severity, and type of disease manifestation. Eosinophilic infiltration and inflammation may result in rhinosinusitis, pneumonitis, gastrointestinal involvement, and cardiomyopathy. The latter, in particular, is associated with a worse prognosis. As a necrotising pauci-immune small-vessel vasculitis, EGPA, similar to the other AAVs, can cause pulmonary infiltrates with alveolar haemorrhage, glomerulonephritis, cutaneous vasculitis with purpura as well as central and peripheral neurologic injuries. The presence of perinuclear ANCA (pANCA) with specificity against myeloperoxidase (MPO) is observed in approximately one-third of patients but is not specific to EGPA. MPO-ANCA-positive patients are more likely to have peripheral neurologic involvement and glomerulonephritis, whereas ANCA-negative patients are more likely to have cardiac and pulmonary involvement. What is frequently challenging in the clinical routine is to differentiate EGPA from the hypereosinophilic syndrome (HES). The therapeutic approach to EGPA depends on whether the severity of the disease is potentially organ or life-threatening. For severe forms of EGPA, acute therapy mainly includes glucocorticoids in combination with cyclophosphamide. Rituximab has come to be mentioned as an alternative treatment option in the guidelines. Various immunosuppressive therapies are available for remission maintenance. In EGPA without severe organ involvement, IL-5 blockade with mepolizumab is an approved treatment.

[Granulomatosis with polyangiitis and microscopic polyangiitis]

Granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) are two entities of ANCA-associated vasculitis (AAV). Both diseases are characterised by systemic necrotising small-vessel vasculitis, which can affect any organ. In GPA, extravascular necrotising granulomatous inflammation, usually affecting the respiratory tract, is found in addition. In the majority of cases, the clinical presentation is dominated by a pulmonary-renal syndrome with alveolar haemorrhage and rapidly progressive glomerulonephritis. Other organ involvement is found as well. In GPA, the upper respiratory tract is commonly affected. GPA is associated with anti-neutrophil cytoplasmic autoantibodies (ANCA) with specificity for proteinase 3 (PR3-ANCA) and MPA with specificity for myeloperoxidase (MPO-ANCA). Immunosuppressive therapy depends on disease activity and the severity of organ involvement.

Use of mesna prophylaxis in patients with cyclophosphamide-treated ANCA-associated vasculitis: cross-sectional survey of practitioners

BACKGROUND

There may be some diversity in the practice of co-prescribing 2-mercaptoethane sodium sulfonate (mesna) with cyclophosphamide (CYC) for ANCA-associated vasculitis (AAV).

OBJECTIVES

To assess the practice of prescribing mesna prophylaxis for CYC-treated patients with AAV.

METHODS

We invited authors of publications on AAV referenced in MEDLINE over the previous 10 years to participate in an anonymous online survey. Respondents were eligible if they were involved in CYC treatments for AAV. The survey asked about the characteristics of the respondents and their practice in using CYC and mesna to treat AAV and the underlying rationale. We compared 18 variables between mesna prescribers and their counterparts to identify factors associated with mesna use.

RESULTS

In total, 139 eligible individuals completed the survey. The participants were from 34 countries and were essentially physicians (98%). Overall, 68%, 19% and 13% of respondents prescribed mesna systematically, never, or on a selective basis. As compared with never/selective-prescribers, systematic-prescribers were more often ≤ 39 years old (P = 0.008), more often used intermittent pulse therapy as the exclusive/predominant CYC administration scheme (P < 0.001), were more frequently based in France/Germany/Italy than in England/United States (P < 0.001), and more often indicated adherence to local standards (P = 0.003) or (inter)national guidelines for AAV (P < 0.001) as a rationale for their mesna practice. Never/selective-prescribers more commonly reported that their mesna prescription pattern had changed as compared with their former practice (P < 0.001).

CONCLUSIONS

Systematic co-prescription of mesna is the prevailing practice for CYC treatments for AAV. The practice seems to involve practicability considerations and differs between generations.

Peripheral Ulcerative Keratitis: Clinical Characteristics, Differential Diagnoses and Therapeutic Concepts

Peripheral ulcerative keratitis (PUK) is an inflammatory disease of the peripheral cornea, which may frequently be associated with several rare, but potentially life-threatening systemic diseases. The inflammatory pathogenesis of PUK results from humoral and cell-mediated inflammation. The diagnosis is usually based on the typical clinical findings and always requires detailed diagnostic testing to identify a potential systemic underlying disease. Treatment includes topical and systemic immunosuppressive and immunomodulatory therapeutic strategies and, in the event of impending or existing perforation, also various surgical interventions. PUK is a potentially blinding disease that initially affects the periphery, but, if left untreated, can lead to destruction of the entire cornea. Interdisciplinary diagnostic testing and therapy are crucial to preserve vision in the affected patients and reduce morbidity and mortality. The following article provides an overview of the pathophysiology, clinical findings, possible underlying systemic diseases, relevant differential diagnoses and therapeutic strategies.

[Cocaine-induced vasculitis and mimics of vasculitis]

Cocaine is a psychotropic tropane alkaloid and stimulant drug. Nasal insufflation of cocaine powder is a common route of administration. In Germany, cocaine is frequently adulterated with levamisole, an anthelminthic drug with immunomodulatory effects. Both substances are linked to various autoimmune conditions. Cocaine-induced midline destructive lesions cause a progressive destruction of osteocartilaginous structures within the upper respiratory tract and can mimic localized granulomatosis with polyangiitis. In addition, systemic vasculitis due to cocaine and levamisole has been reported. Differentiation of these conditions from primary vasculitis can be challenging because antineutrophil cytoplasmic antibodies (ANCA) are commonly detected. Early diagnosis of these conditions is crucial as clinical improvement is closely related to drug cessation.

[Eosinophilia: hypereosinophilic syndrome vs. eosinophilic granulomatosis with polyangiitis]

Hypereosinophilic syndrome (HES) is defined as a peripheral eosinophil count of > 1500/μl (assessed twice at an interval of ≥ 2 weeks) and an eosinophil-induced organ damage. Idiopathic HES is differentiated from primary (clonal or neoplastic) HES and secondary (reactive) HES, depending on the etiology. Eosinophilic granulomatosis with polyangiitis (EGPA) is categorized as a secondary form of HES and is characterized by hypereosinophilia and vasculitis of small to medium-sized vessels and can be associated with an antineutrophil cytoplasmic antibody (ANCA). The treatment of HES is dependent on the etiology. Clonal HES is treated according to the respective genetic aberration, e.g. with tyrosine kinase inhibitors or chemotherapy and allogenic stem cell transplantation. Secondary forms should be treated according to the underlying cause (e.g. parasitic infection). The treatment of EGPA is carried out with immunosuppressants depending on the disease stage and disease activity. Conventional drugs, such as glucocorticoids (GC), cyclophosphamide (CYC) and methotrexate (MTX) or biologics, such as the monoclonal anti-IL5 antibody mepolizumab are commonly used. Mepolizumab is also a good option for the treatment of idiopathic HES.

[Consensus guideline on the interdisciplinary diagnosis of interstitial lung diseases]

The evaluation of a patient with interstitial lung disease (ILD) includes assessment of clinical, radiological, and often histopathological data. As there were no specific recommendations to guide the evaluation of patients under the suspicion of an ILD within the German practice landscape, this position statement from an interdisciplinary panel of ILD experts provides guidance related to the diagnostic modalities which should be used in the evaluation of ILD. This includes clinical assessment rheumatological evaluation, radiological examinations, histopathologic sampling and the need for a final discussion in a multidisciplinary team.

[Autoimmune diagnostics in nephrology and rheumatology]

Autoimmune diagnostics plays a central role in the detection of various acute and/or chronic diseases in both nephrology and rheumatology, which are associated with high morbidity and mortality if left untreated or not detected in time. Patients are threatened with significant limitations in everyday skills and quality of life due to loss of kidney function and dialysis, immobilizing and destructive joint processes or also significant damage of organ systems. In all of these autoimmune diseases, early diagnosis and treatment is of central importance for the further course and prognosis of disease.Antibodies play an essential role in the pathogenesis of autoimmune diseases. Antibodies are either directed against organ or tissue-specific antigens, such as in primary membranous glomerulonephritis or Goodpasture's syndrome, or they lead to a systemic disease such as systemic lupus erythematosus (SLE) or rheumatoid arthritis.Knowledge of the sensitivity and specificity of antibodies is crucial for the interpretation of antibody diagnostics results. Antibody detection can precede the clinical onset of the disease, and antibody titers often reflect disease activity. However, there are also false positive results. Detection of antibodies in the absence of disease symptoms often leads to uncertainty and unnecessary further diagnostics. Therefore, an unfounded "antibody screening" is not recommended.A rational antibody diagnostics is an integral part of the diagnostics and during treatment of nephrological and rheumatological diseases like glomerulonephrititis, pulmorenal syndrome, SLE and other collagenosis, thrombotic microangiopathy (HUS/TTP) and rheumatoid arthritis.

The impact of a structured one-day seminar on disease-specific knowledge, lifestyle habits and disease impairment in ANCA-associated vasculitis. Results of a randomized, controlled study

OBJECTIVE

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a complex, chronic autoimmune disease, and its diagnosis triggers considerable anxiety and uncertainty for those affected. There are currently no valid data describing the impact of disease-specific patient education on the disease knowledge, subjective impairment, and changes in lifestyle habits related to AAV.

METHOD

We designed a one-day educational programme to serve AAV patients with information about their disease and its treatment. Patients were randomized into an intervention group and a waiting list control group. Increase in knowledge was measured with a multiple-choice test. The intervention group completed the questionnaire before, directly after, and 3 months after the seminar, while the waiting list control group was additionally tested 3 months before the seminar to rule out non-specific learning. Furthermore, we investigated the burden of the disease and the impact of our intervention on this burden.

RESULTS

Compared with the control group, the intervention increased the knowledge (mean ± sd score difference 2.2 ± 1.0, 95% confidence interval 0.1-4.3, p = 0.04). From the patients' point of view, their understanding of the disease had improved and the subjective impairment caused by their rheumatic disease had decreased. There was a tendency to include disease-relevant behaviour, such as nasal care or dietary recommendations, more often in everyday life.

CONCLUSION

A one-day seminar is suitable to increase the disease-specific knowledge of patients with AAV in a sustainable manner. In addition, our measure positively affected the disease-relevant behaviour.

Favourable outcome of acute hepatitis E infection in patients with ANCA-associated vasculitis

BACKGROUND

Hepatitis E virus (HEV) infection is a frequent cause of acute viral hepatitis. Immunocompromised patients are at increased risk for viral infection and chronic courses of hepatitis. Whether patients with autoimmune diseases are at risk of developing clinically relevant hepatitis or even chronic liver disease after HEV infection is discussed controversially. ANCA-associated vasculitis is a rare autoimmune disease with potentially life-threatening organ involvement, thus requiring intensive immunosuppression with glucocorticoids, cyclophosphamide, or rituximab. As there are no reports available on the infection with HEV in patients with ANCA-associated vasculitis, clinical decision making in such cases is based on experiences from other disease entities. Therefore, in this study we analyzed the course of liver disease and the therapeutic management of autoimmune vasculitis in a retrospective cohort of five patients with ANCA-associated vasculitis and acute hepatitis E.

RESULTS

Four patients were on immunosuppressive maintenance therapy and one patient was on remission induction therapy with cyclophosphamide and high dose glucocorticoids. All patients had at least one potentially hepatotoxic co-medication at the time of hepatitis. Hepatitis-associated clinical symptoms were recorded in four of five patients. The course of hepatitis was characterized by strongly elevated transaminases, a temporary liver failure was observed in one case. The management of hepatitis E included cessation of the immunosuppressants in all patients, whereas oral glucocorticoids were not discontinued. Under this regime, all patients cleared the virus without additional anti-viral treatment. Liver enzymes normalized one month after they peaked. In the follow-up period of at least 1.5 years (range 1.5-12 years), no chronic liver disease was observed, although one patient died of cholangiocarcinoma with liver metastases some years after HEV infection. Vasculitis was not active in our patient cohort at the time of HEV infection. However, inflammatory flares occured in three of five patients after discontinuation of the immunosuppressive therapy. Immunosuppressants were paused for a median time of 4 weeks and after their resumption vasculitic disease activity was controlled in all patients.

CONCLUSIONS

Acute HEV infection in patients with ANCA-associated vasculitis shows a favorable outcome of liver disease but bears the risk of inflammatory flares due to cessation of immunosuppression.

Granulomatose mit Polyangiitis und mikroskopische Polyangiitis

Die Granulomatose mit Polyangiitis (GPA) und mikroskopische Polyangiitis (MPA) sind zwei zur ANCA-assoziierten Vaskulitis (AAV) zählende Entitäten. Beiden Erkrankungen liegt eine systemische nekrotisierende Kleingefäßvaskulitis zugrunde, die jedes Organ betreffen kann. Bei der GPA ist zusätzlich eine in der Regel den Respirationstrakt betreffende extravaskuläre nekrotisierende granulomatöse Entzündung vorzufinden. Das klinische Bild wird in der Mehrzahl der Fälle durch ein pulmo-renales Syndrom mit alveolärer Hämorrhagie und rapid-progressiver Glomerulonephritis sowie weitere Organmanifestationen bestimmt. Bei der GPA imponiert zudem die fast regelhafte Mitbeteiligung des oberen Respirationstrakts. Die GPA ist mit Anti-Neutrophilen zytoplasmatischen Autoantikörpern (ANCA) mit einer Spezifität für die Proteinase 3 (PR3-ANCA) und die MPA für Myeloperoxidase (MPO-ANCA) assoziiert. Die immunsuppressive Therapie richtet sich nach der Krankheitsaktivität und Schwere der Organbeteiligung.

Eosinophile Granulomatose mit Polyangiitis – ein Übersichtsartikel

Die eosinophile Granulomatose mit Polyangiitis (EGPA) ist eine seltene Form der ANCA-assoziierten Vaskulitiden (AAV) aus der Gruppe der Kleingefäßvaskulitiden. Sie ist definiert als eine Vaskulitis kleiner und mittelgroßer Gefäße mit granulomatöser Entzündung sowie Blut- und Gewebseosinophilie. Fast alle Patienten haben allergische Symptome mit Asthma bronchiale und rhinosinusitischen Beschwerden. Das sonstige klinische Spektrum variiert je nach Lokalisation, Schweregrad und Art der Krankheitsmanifestation. Durch die eosinophile Infiltration und Inflammation kann es zu Rhinosinusitis, Pneumonitis, gastrointestinaler Beteiligung und Kardiomyopathie kommen. Insbesondere Letztere ist mit einer schlechteren Prognose assoziiert. Als nekrotisierende pauci-immune Kleingefäßvaskulitis kann die EGPA, ähnlich wie die anderen AAV, pulmonale Infiltrate mit alveolärer Hämorrhagie, eine Glomerulonephritis, kutane Vaskulitis mit Purpura, sowie zentrale und periphere neurologische Schädigungen verursachen. Das Auftreten perinukleärer ANCA (pANCA), mit Spezifität gegen die Myeloperoxidase (MPO) wird in etwa einem Drittel der Fälle beobachtet, ist allerdings nicht spezifisch für die EGPA. MPO-ANCA-positive Patienten haben häufiger eine periphere neurologische Beteiligung und eine Glomerulonephritis, während ANCA-negative Patienten häufiger eine kardiale und pulmonale Beteiligung aufweisen. Eine differentialdiagnostische Herausforderung im klinischen Alltag stellt die Abgrenzung zum hypereosinophilen Syndrom (HES) dar. Das Therapiekonzept der EGPA hängt davon ab, ob der Schweregrad der Erkrankung potentiell Organ- oder lebensbedrohlich ist. Bei schweren Formen der EGPA werden in der Akuttherapie hauptsächlich Glukokortikoide in Kombination mit Cyclophosphamid eingesetzt. Rituximab wird mittlerweile als alternative Behandlungsoption in den Leitlinien genannt. Zur Remissionserhaltung stehen verschiedene immunsuppressive Therapien zur Verfügung. Bei EGPA ohne schwere Organbeteiligung ist die IL-5 Blockade mit Mepolizumab zugelassen.

[ANCA-associated vasculitis]

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are rheumatic diseases characterized by small-to-medium vessel vasculitis. Three different entities can be distinguished: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA). While lung and renal involvement are typical manifestations of both GPA and MPA, EGPA usually shows paranasal sinus and lung involvement as well as a history of bronchial asthma. Furthermore, EGPA is frequently associated with cardiac disease and peripheral neuropathy. Cyclophosphamide or rituximab, combined with glucocorticoids, are used to induce remission of severe disease. Maintenance therapy options include rituximab as the first-line treatment, as well as methotrexate or azathioprine plus low-dose glucocorticoids.

[Granulomatous vasculitides and vasculitides with extravascular granulomatosis]

Vasculitides are inflammatory diseases of blood vessels caused by autoimmune or infectious processes, which are associated with alterations and destruction of the vascular wall. From a histopathological point of view, granulomatous vasculitides can be distinguished from necrotizing vasculitides with respect to the pattern of inflammation. Granulomatous vasculitides are characterized by intramural, predominantly lymphohistiocytic infiltrates with the formation of giant cells. They include giant cell arteritis (GCA) and Takayasu arteritis (TAK). By contrast, anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) belongs to the group of necrotizing vasculitides. AAV includes granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). In addition to systemic necrotizing small vessel vasculitis, GPA and EGPA are characterized by extravascular granulomatous necrotizing inflammation mainly affecting the upper and/or lower respiratory tract, in EGPA with eosinophilic infiltrates. These granulomatous lesions are part of the autoimmune process and associated with tissue damage.

Differentialdiagnose Vaskulitis und Vaskulopathie aus dermatologischer Sicht

Vaskulopathien und Vaskulitiden stellen diagnostisch und therapeutisch eine interdisziplinäre Herausforderung dar. Zugrunde liegen unterschiedliche pathophysiologische Mechanismen, die zu vielfältigen klinischen Krankheitsbildern führen können und therapeutisch unterschiedliche Ansätze erlauben. Sowohl Vaskulitiden als auch Vaskulopathien müssen nicht zwangsläufig mit einer Systembeteiligung einhergehen, sondern können auch als rein kutane Varianten auftreten. Aufgrund mangelnder pathognomonischer Laborparameter ist die Diagnose häufig klinisch zu stellen. Dieser Artikel soll den differentialdiagnostischen Blick, insbesondere auf die kutanen Manifestationsformen bei Vaskulopathien und Vaskulitiden, schärfen.

[Update on etiopathogenesis of small vessel vasculitis]

Small vessel vasculitis is characterized by a necrotizing inflammation of the vessel wall predominantly with involvement of small intraparenchymal arteries, arterioles, capillaries and venules. Medium-sized and occasionally large vessels can also be involved. Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis) are differentiated from immune complex vasculitides based on immunopathological and serological aspects. Immune complex vasculitides include IgA vasculitis, cryoglobulinemic vasculitis, hypocomplementemic urticarial vasculitis (anti-C1q vasculitis) and anti-glomerular basement membrane disease. Epidemiological and next-generation sequencing-based studies have significantly contributed to the identification of predisposing environmental factors and genetic risk factors in recent years. Under specific conditions ANCA and immune complexes can induce premature intravascular activation of neutrophilic granulocytes with degranulation and release of enzymes and reactive oxygen species, which leads to vascular damage. In granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis various factors, such as barrier dysfunction and dysbiosis of the microbiome contribute to extravascular granuloma formation predominantly affecting the respiratory tract.

[Eosinophilic granulomatosis with polyangiitis : Update on classification and management]

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare chronic inflammatory systemic disease that occurs in patients with bronchial asthma and is associated with significant blood and tissue eosinophilia. Another characteristic is vasculitis of small and/or medium-sized vessels, which may be absent in prodromal stages of the disease and is therefore no longer an obligatory part of the disease definition. Antineutrophil cytoplasmic antibodies (ANCA) can be detected in approximately one third of patients. The ANCA-positive and ANCA-negative EGPA are genetically distinct diseases with common clinical manifestations, which, however, occur with different frequencies. Cardiac involvement is associated with a poor prognosis. Permanent organ damage often occurs as a result of the underlying disease or treatment, especially with glucocorticoids (GC). The standard treatment of EGPA consists of GC in combination with cyclophosphamide for severe organ involvement or medium potency immunosuppressants for more prognostically favorable manifestations. Biologics are increasingly being used in the treatment of EGPA. The interleukin (IL) 5 antagonist mepolizumab reduces the risk of relapses and decreases the demand for GC in patients with relapsing EGPA without severe organ involvement. In analogy to the approach to other ANCA-associated vasculitides, the use of rituximab in ANCA-positive EGPA patients with severe vasculitis recurrence is a possible option, even though formal evidence for such an approach is currently low and formal approval is lacking.

[Biologics for connective tissue diseases and vasculitides]

Despite therapy with glucocorticoids (GC) and conventional immunosuppressants, patients with connective tissue diseases and vasculitides often develop functionally relevant and prognostically unfavourable internal organ damage. Based on new pathogenetic insights, biologics and small molecules have recently been studied as targeted therapies for collagen vascular diseases and vasculitides. The B lymphocyte stimulator antagonist belimumab has been used for the treatment of systemic lupus erythematosus (SLE) for several years and has recently also been approved as an add-on therapy for lupus nephritis. Anifrolumab, an antibody against the type‑1 interferon receptor, has also been shown to be effective in phase III trials for the treatment of SLE. The interleukin (IL)-6-antagonist tocilizumab showed efficacy in the treatment of interstitial lung disease (ILD) in systemic sclerosis (SSc) and thus has been approved in the USA, although the phase III trial had a negative primary endpoint. In Europe the tyrosine inhibitor nintedanib is approved for progressive ILD in SSc. Tocilizumab is approved for the treatment of giant cell arteritis and reduces both the risk of recurrence and the cumulative GC requirement. The B‑lymphocyte depleting antibody rituximab is approved for induction and maintenance therapy of granulomatosis with polyangiitis and microscopic polyangiitis (MPA) and is currently also being investigated for the treatment of eosinophilic granulomatosis with polyangiitis (EGPA). In patients with EGPA, the IL‑5 antibody mepolizumab leads to improved disease control and reduces GC requirements. A phase III trial of the small molecule antagonist avacopan targeting the complement C5a receptor as a replacement for high-dose GC in induction therapy of GPA and MPA met its primary endpoints. Various other biologics and small molecule antagonists are currently in clinical development for several type of vasculitis and collagen vascular diseases, some of them at advanced stages.

[Glucocorticoid-induced osteoporosis-Focus treatment (part 1)]

With a fracture prevalence of 30-50%, glucocorticoid (GC)-induced osteoporosis is one of the most important comorbidities in inflammatory rheumatic diseases. Because of a reduction of bone quality with a lack of correlation with bone mineral density, the fracture risk during long-term GC treatment is not sufficiently represented by the currently available methods of osteodensitometry and therefore underestimated. According to the Confederation for Osteology (DVO) guidelines, a baseline osteological diagnosis including osteodensitometry is indicated in all postmenopausal women and in men aged 60 years and older who receive or are scheduled to receive GC at a dose of ≥ 2.5 mg prednisolone equivalent/day for > 3 months. Basic measures in GC-treated patients include vitamin D and calcium supplementation as well as measures to promote muscle strength and coordination and to prevent falls. The indications for a specific osteological treatment depend on the calculated GC dose, age, sex, and other fracture risk factors in addition to bone mineral density and prevalent fractures.

Case report: Idiopathic subglottic stenosis in a girl; successful treatment with macrolides

An 8-year-old girl presented with treatment-refractory cough and inspiratory stridor. Bronchoscopies showed progressive scarring leading to narrowing of the proximal trachea (Myer-Cotton Grade 2) and epithelial metaplasia of the tracheal and bronchial mucosa. After excluding other causes of congenital and acquired tracheal stenosis, an idiopathic subglottic tracheal stenosis (iSGS) was diagnosed. Because of the patient's young age, a judicious therapeutic approach seemed appropriate. Therapy with azithromycin, followed by roxithromycin, was started. Symptoms almost completely subsided, spirometry normalized, and endoscopic and histologic findings improved considerably. Therapy has been continued for more than 3 years with normal lung function values, and no compromise on physical activities and development. In instances of iSGS, therapy with macrolides is worth considering before more invasive procedures such as dilatation, laser, intralesional injections, or surgical resection are performed.

Organ Manifestation and Systematic Organ Screening at the Onset of Inflammatory Rheumatic Diseases

BACKGROUND

Inflammatory rheumatic diseases (IRD) are often associated with the involvement of various organs. However, data regarding organ manifestation and organ spread are rare. To close this knowledge gap, this cross-sectional study was initiated to evaluate the extent of solid organ manifestations in newly diagnosed IRD patients, and to present a structured systematic organ screening algorithm.

MATERIALS AND METHODS

The study included 84 patients (63 women, 21 men) with newly diagnosed IRD. None of the patients received any rheumatic therapy. All patients underwent a standardised organ screening programme encompassing a basic screening (including lungs, heart, kidneys, and gastrointestinal tract) and an additional systematic screening (nose and throat, central and peripheral nervous system) on the basis of clinical, laboratory, and immunological findings.

RESULTS

Represented were patients with connective tissue diseases (CTD) (72.6%), small-vessel vasculitis (16.7%), and myositis (10.7%). In total, 39 participants (46.5%) had one or more organ manifestation(s) (one organ, 29.7%; two organs, 10.7%; ≥three organs, 6.0%). The most frequently involved organs were the lungs (34.5%), heart (11.9%), and kidneys (8.3%). Lastly, a diagnostic algorithm for organ manifestation was applied.

CONCLUSION

One-half of the patients presented with a solid organ involvement at initial diagnosis of IRD. Thus, in contrast to what has been described in the literature, organ manifestations were already present in a high proportion of patients at the time of diagnosis of IRD rather than after several years of disease. Therefore, in IRD patients, systematic organ screening is essential for treatment decisions.

[High burden of disease in patients with ANCA-associated vasculitis : A claims data study in Germany]

Hintergrund und Zielsetzung

Unter dem Begriff der mit antineutrophilen zytoplasmatischen Antikörpern (ANCA) assoziierten Vaskulitis (AAV) wird eine Gruppe seltener, chronischer, durch rezidivierende systemische Entzündungen gekennzeichneter Autoimmunerkrankungen mit vielfältigen Morbiditäten zusammengefasst. Patienten mit AAV leiden unter diversen Organmanifestationen und schweren Nebenwirkungen der Therapie. In dieser retrospektiven Studie wurde die konkrete Belastung der Patienten durch die AAV-Erkrankung in Deutschland untersucht.

Methodik

Basierend auf anonymisierten Längsschnittdaten der gesetzlichen Krankenversicherung (GKV) zur medizinischen Versorgung zwischen 2013 und 2016 wurden aus einer repräsentativen Kohorte von etwa 3 Mio. Versicherten Patienten mit Granulomatose mit Polyangiitis (GPA) und mikroskopischer Polyangiitis (MPA) identifiziert und ausgewählte klinische Aspekte systematisch analysiert.

Ergebnisse

Die häufigsten begleitenden Morbiditäten von GPA und MPA waren Nieren- und Atemwegserkrankungen. Eine schwere Nierenbeteiligung trat bei 11,6 % der GPA- und 24,3 % der MPA-Patienten innerhalb von 15 Quartalen nach der Diagnose auf. Bei einem Drittel der Patienten mit AAV entwickelten sich innerhalb der ersten 3 Quartale nach Diagnose schwere Infektionen. Die Rate der schweren Rezidive betrug jährlich 5–8 %. Patienten mit AAV und Nierenbeteiligung oder Infektionen zeigten zudem eine hohe jährliche Mortalitätsrate von 14,4 % bzw. 5,6 %.

Schlussfolgerung

Anhand dieser Analyse deutscher Versorgungsdaten wurden krankheitsspezifische Annahmen der Belastung von Patienten mit AAV bestätigt und für den deutschen Kontext konkretisiert. Patienten mit AAV leiden unter einer hohen Morbiditätsbelastung, einschließlich multipler Krankheitsmanifestationen, Rezidiven und schwerer Komplikationen aufgrund der AAV-Therapie.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00108-021-01181-z) enthält eine zusätzliche Tabelle sowie zwei weitere Abbildungen.

[Arthritis and pulmonary cavities]

This case report describes the very rare simultaneous occurrence of rheumatoid arthritis and granulomatosis with polyangiitis with the only organ manifestation of life-threatening bilateral pulmonary cavities. Due to the acuteness of the vasculitis, treatment was primarily with cyclophosphamide infusions and high-dose glucocorticoids, and in the further course with high-dose methotrexate. Routine thoracic imaging also seems to be useful when conventional basic rheumatologic treatment is newly initiated, as treatment-decisive changes are seen with a relevant frequency. The occurrence of both autoimmune diseases might be due to common genetic predispositions.

Risikostratifizierung bei ANCA-assoziierten Vaskulitiden

ANCA-assoziierte Vaskulitiden (AAV) sind nekrotisierende Vaskulitiden der kleinen bis mittelgroßen Gefäße, welche die Granulomatose mit Polyangiitis (GPA), die mikroskopische Polyangiitis (MPA) und die Eosinophile Granulomatose mit Polyangiitis (EGPA) umfassen. AAV gehen häufig mit Organfunktion-bedrohenden Manifestationen und einer entsprechend erhöhten Mortalität einher. Für die Planung von Diagnostik, Therapie und Langzeitbetreuung ist daher eine Risikostratifizierung im Hinblick auf Mortalität, Entwicklung schwerer Organinsuffizienzen, insbesondere einer terminalen Niereninsuffizienz, mögliche Therapieresistenz, Rezidive, Infektionen und Malignome erforderlich. Wichtige Risikofaktoren für erhöhte Mortalität und/oder terminale Niereninsuffizienz sind neben der renalen Beteiligung per se eine bereits zum Zeitpunkt der Diagnose deutlich eingeschränkte renale Funktion einschliesslich initialer Dialysepflichtigkeit, eine hohe initiale Aktivität der AAV gemessen am Birmingham Vaskulitis Activity Score, aber auch kardiale und gastrointestinale Manifestationen, Infektionen, Anämie sowie ein Alter von>65 Jahren. Histologisch ist der Nachweis chronischer irreversibler glomerulärer und tubulärer Läsionen in der Nierenbiopsie mit einer schlechten Prognose im Hinblick auf die Nierenfunktion assoziiert. Basierend auf der histopathologischen Klassifikation der ANCA-assoziierten Glomerulonephritis (GN) ist der Befund einer sklerosierenden GN mit einer besonders ungünstigen Prognose assoziiert, während die fokale GN sehr selten zur terminalen Niereninsuffizienz führt. MPO-ANCA zeigen eine Assoziation mit chronischen Läsionen in der Nierenbiopsie sowie erhöhter Mortalität und erhöhtem Risiko für terminale Niereninsuffizienz. Im Hinblick auf die pulmonale Beteiligung sind alveoläre Hämorrhagie und interstitielle Lungenerkrankung mit einer erhöhten Mortalität assoziiert. Bei EGPA wird die Prognose entscheidend durch die Kardiomyopathie bestimmt. Risikofaktoren für Rezidive weichen erheblich von denen für Mortalität und terminale Niereninsuffizienz ab. Ein erhöhtes Rezidivrisiko besteht bei Nachweis von PR3-ANCA, GPA und pulmonaler Beteiligung. Auch bei granulomatösen Läsionen, Beteiligung des oberen Respirationstraktes und kardiovaskulären Manifestationen wird ein erhöhtes Rezidivrisiko beschrieben. Im Gegensatz zur Assoziation einer initial schlechten Nierenfunktion mit Mortalität und terminaler Niereninsuffizienz, wurde für Patienten mit initial guter Nierenfunktion ein erhöhtes Rezidivrisiko gezeigt. Weitere Risikofaktoren für Rezidive sind Staphylokokken-Besiedelung der Nase, frühere Rezidive und ANCA-Positivität nach Remissionsinduktion. Titeranstieg oder Wiederauftreten von ANCA zeigen nur eine moderate Beziehung zum Rezidivrisiko. Der prädiktive Wert für Rezidive ist offenbar bei bestimmten Subgruppen, wie bei Patienten mit renaler Beteiligung und pulmonaler Hämorrhagie sowie bei mit Rituximab-behandelten Patienten besser als bei Patienten mit granulomatösen Manifestationen. Daher ist eine Therapieentscheidung allein auf Basis der Entwicklung der ANCA-Titer nicht möglich. Risikofaktoren für schwere Infektionen sind höher dosierte und prolongierte Glukokortikoidtherapie, Leuko- und Lymphopenie, höheres Lebenalter, Niereninsuffizienz und pulmonale Beteiligung. Die Malignomrate insbesondere für Nicht-Melanom-Hauttumoren, Harnblasenkarzinome und Leukämie ist bei AAV erhöht und zeigt eine Assoziation mit hohen kumulativen Cyclophosphamiddosen. Da insbesondere frühzeitige irreversible Organschäden die Prognose bestimmen und Rezidive die Entwicklung irreversibler Schäden treiben, sind frühestmögliche Diagnose und Therapie sowie rasches Erkennen und Vermeiden von Rezidiven essentiell für die Risikominimierung.

[Cortisone-free rheumatology-Vasculitides]

Glucocorticoids (GC) still represent an essential pillar of treatment in the phase of remission induction of vasculitides, which are often organ or life-threatening; however, they entail a significant potential for side effects. In the phase of remission maintenance prednisolone should be reduced to 7.5 mg/day or less. Whether a discontinuation can alway be achieved for any form of vasculitis without increasing relapse rates, is unclear. By the use of biologics, e.g. tocilizumab in giant cell arteritis (GCA), a fast tapering and discontinuation of GC seems to be more easily achievable compared to using a GC monotherapy regimen. Avacopan could in the future be an efficient agent to spare GC in the phase of remission induction in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), e.g. granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). Mepolizumab is a promising option to reduce the use of GC in eosinophilic granulomatosis with polyangiitis (EGPA).

[Hemoptysis and acute kidney injury in COVID-19]

The present case describes the diagnostic and therapy of the pulmorenal syndrome of a 40-year-old patient who presented in our clinic due to increasing respiratory insufficiency and hemoptysis with confirmed COVID-19 disease.

[Regional cooperative rheumatology centers : Networking of rheumatology in Germany for over 25 years]

Over the last 25 years the regional collaborative rheumatology centers have become established throughout Germany as "catalysts" for improving rheumatological care at many different levels. With campaigns and a multitude of activities they have promoted the visibility of rheumatology in Germany together with rheumatological alliance partners and, on the scientific side, together with the German Rheumatism Research Center have contributed to the improvement of rheumatological care research in Germany. The regional cooperative rheumatology centers have become an important partner in the rheumatology network in their association as a working group of the German Society for Rheumatology and they will continue to face new tasks in the future to further improve rheumatological care in Germany.

[Daptomycin-induced eosinophilic pneumonia associated with an early endoprosthesis infection]

Acute eosinophilic pneumonia (AEP) is a rare disease characteristically involving eosinophilic infiltration of lung parenchyma as well as fever, dyspnea, and coughing. A differentiation is made between primary and secondary AEP depending on the underlying etiology. Substances that most frequently cause secondary AEP are antibiotics, such as the lipopeptide daptomycin. This is a case report about a 69-year-old female patient who underwent antibiotic treatment with daptomycin for an infection of a knee prosthesis. During the treatment, signs of pneumonia developed and included the increased dependence on mechanical ventilation of the previously intubated patient, infiltrates on a chest X‑ray, fever, and an increase in serum inflammation markers. Proof of bacteria as an underlying pathogen was not possible. A thoracic computed tomography (CT) scan showed opacities that are commonly seen in interstitial lung disease. Termination of daptomycin treatment due to renal failure led to an improvement of pulmonary symptoms. Re-exposure to daptomycin resulted in a recurrence of the symptoms. The diagnostic criteria for AEP according to Uppal et al. include 1) current exposure to daptomycin, 2) dyspnea with increased oxygen requirements or necessity for mechanical ventilation, 3) new infiltrates on chest X‑ray or CT scan, 4) bronchoalveolar lavage with eosinophilia >25%, 5) improvement of clinical symptoms following daptomycin withdrawal, and 6) fever. With 5 out of the 6 criteria by Uppal et al. positive-an eosinophilia >25% being the only unmet criteria-an AEP induced by daptomycin was diagnosed. Withdrawal of daptomycin as well as high-dose cortisol bolus treatment led to a rapid recovery.

[Current treatment of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)]

For the treatment of eosinophilic granulomatosis with polyangiitis (EGPA) much less data are available when compared to the other anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). At the same time EGPA also differs in many aspects from AAVs. Treatment is guided by the German and international guidelines. An adapted induction therapy is chosen depending on the disease activity, manifestations and factors determining the prognosis. For patients without negative prognostic factors glucocorticoids alone may be sufficient. A medium potent immunosuppressive agent may be added in order to economize on steroids. For patients with severe organ manifestations and adverse prognostic factors, a highly potent immunosuppression usually with cyclophosphamide, is necessary. In cases of remission a maintenance therapy is recommended in the same way as for other AAVs. Recently, a biological, the IL-5 antibody mepolizumab has also become available, although its precise role still has to be established.

[Rheumatological care in the Rheumazentrum Ruhrgebiet Rheumatism Center-a model for conurbations]

The Ruhrgebiet Rheumatism Center, which is highly specialized for rheumatic diseases, is the largest of its kind in Germany. For many years it has fulfilled all the requirements for structural quality required by the Association of Rheumatological Acute Clinics (VRA) including regular participation in the KOBRA benchmarking project. Therefore, the center regularly receives the VRA seal for quality of care. In 2018 more than 7500 patients were treated as inpatients. Within the framework of care according to §116b (ASV since May 2019) there were nearly 25,000 outpatient patient contacts. Furthermore, an early screening program (triage) was established 5 years ago in order to be able to identify patients with musculoskeletal complaints on a potentially inflammatory rheumatic basis. This functions in the sense of an early diagnosis and treatment in accordance with the treat-to-target concept within less than 4 weeks (initially) on an outpatient basis with respect to the required urgency, in order to subsequently provide sound diagnostic support. In the last 2 years 2017 and 2018, this deadline was met in more than 90% of cases. Within the scope of inpatient care approximately one third of patients were treated in recent years with a defined rheumatological complex therapy and 10% with pain complex therapy. Approximately 3% were treated with geriatric complex therapy and 65% were short-stay patients (<4 days), i.e. patients who received the necessary diagnostics and treatment on an inpatient basis at short notice. The overall structure of the rheumatism center, the cooperation with rheumatologists in private practice, many cooperation partners, referring physicians and patients represents a model for rheumatological care in large conurbations. The care of large numbers of patients also enables the further training of many assistants and this is essential for the future of good rheumatological medicine.

[Differentiated laboratory diagnostics of rheumatic diseases]

Laboratory diagnostics of rheumatic diseases include examinations to confirm the diagnosis, estimate prognosis, assess disease activity as well as recognition and avoidance of complications. Although detection and clinical classification of serological signs of inflammation are the first and often decisive steps in the diagnosis of inflammatory rheumatic diseases, a lack of humoral signs of inflammation does not rule out an inflammatory rheumatic disease. Rheumatological and immunological laboratory diagnostics should always be assessed in the context of the clinical issue and other clinical and technical findings.

[What are the indications for rescue procedures? : Systemic rheumatic diseases in the intensive care unit]

Schwere, organ- oder lebensbedrohliche Manifestationen entzündlicher rheumatischer Erkrankungen, wie z. B. eine diffuse alveoläre Hämorrhagie im Rahmen einer Kleingefäßvaskulitis, sprechen nicht immer ausreichend oder mit zeitlicher Verzögerung auf eine immunsuppressive Therapie an. Bei einem drohenden oder bereits eingetretenen Organversagen besteht dann nicht selten die Notwendigkeit, die immunsuppressive Therapie auf der Intensivstation um rasch wirksame Rescue-Therapieverfahren zu ergänzen. Aufgrund der Seltenheit vieler rheumatischer Erkrankungen ist die Evidenz zum Einsatz von Rescue-Therapieverfahren wie der Plasmapherese, der extrakorporalen Membranoxygenierung (ECMO) oder der Gabe von intravenösen Immunglobulinen (IVIG) für viele Indikationen eher gering. Der Einsatz der Plasmapherese wird bei einer akuten Anti-GBM(glomeruläre Basalmembran)-Erkrankung (Goodpasture Syndrom) oder einem katastrophalen Antiphospholipidantikörpersyndrom (CAPS) als sinnvoll angesehen. Eine ECMO-Therapie kann bei persistierender respiratorischer Insuffizienz trotz mechanischer Beatmung als Folge einer diffusen alveolären Hämorrhagie oder eines Acute-Respiratory-Distress-Syndroms (ARDS) anderer Ursache erwogen werden. Eine Gabe von IVIG ist bei einer akuten kardialen Beteiligung im Rahmen einer Kawasaki-Erkrankung indiziert und kann beim CAPS sowie bei therapierefraktären Myositiden erwogen werden.

Cerebral involvement in systemic vasculitides: Extracts from the guideline of the German neurological society

Cerebral vasculitis is a rare disorder but plays a major role in the differential diagnosis of stroke, encephalopathy and headache. This guideline was developed in order to support clinicians in the diagnosis and treatment of cerebral manifestations of systemic vasculitides and rheumatic diseases. It is based on a medline research and was developed in a modified Delphi process and approved by the involved societies. This article is an abridged and translated version of the guideline published in DGNeurologie: Berlit, P. & Krämer, M. DGNeurologie (2018) 1: 17. 10.1007/s42451-018-0001-y.

[ANCA-associated vasculitides : State of the art]

Granulomatosis with polyangiitis (GPA, formerly Wegener's granulomatosis) and microscopic polyangiitis (MPA) are associated with the detection of antibodies against neutrophilic cytoplasmic antigens (ANCA) and are referred to as ANCA-associated vasculitides (AAV). In the event of the clinical suspicion of AAV the ANCA should first be determined by means of an antigen-specific immunoassay for proteinase 3‑ANCA and myeloperoxidase-ANCA, according to current consensus recommendations. The diagnosis of AAV should also be confirmed by biopsy if possible. The classification criteria for AAV are currently being revised. Diagnostic criteria do not exist. The standard induction therapy consists of rituximab or cyclophosphamide, each in combination with glucocorticoids (GC). In the absence of severe organ involvement, methotrexate can alternatively be used. Recent study data suggest that additive plasmapheresis does not improve the long-term outcome. After remission, remission-preserving treatment with azathioprine, methotrexate or rituximab should be given for at least 48 months. The risk of severe infections is markedly increased, especially during the remission induction phase but can also be reduced during treatment with rituximab by the prophylactic administration of trimethoprim-sulfamethoxazole. In view of the increased risk of infection, GC-reduced or GC-free treatment regimens are currently the focus of clinical development.

Pathogenetic and Clinical Aspects of Anti-Neutrophil Cytoplasmic Autoantibody-Associated Vasculitides

Anti-neutrophil cytoplasmic autoantibodies (ANCA) targeting proteinase 3 (PR3) and myeloperoxidase expressed by innate immune cells (neutrophils and monocytes) are salient diagnostic and pathogenic features of small vessel vasculitis, comprising granulomatosis with polyangiitis (GPA), microscopic polyangiitis, and eosinophilic GPA. Genetic studies suggest that ANCA-associated vasculitides (AAV) constitute separate diseases, which share common immunological and pathological features, but are otherwise heterogeneous. The successful therapeutic use of anti-CD20 antibodies emphasizes the prominent role of ANCA and possibly other autoantibodies in the pathogenesis of AAV. However, to elucidate causal effects in AAV, a better understanding of the complex interplay leading to the emergence of B lymphocytes that produce pathogenic ANCA remains a challenge. Different scenarios seem possible; e.g., the break of tolerance induced by a shift from non-pathogenic toward pathogenic autoantigen epitopes in inflamed tissue. This review gives a brief overview on current knowledge about genetic and epigenetic factors, barrier dysfunction and chronic non-resolving inflammation, necro-inflammatory auto-amplification of cellular death and inflammation, altered autoantigen presentation, alternative complement pathway activation, alterations within peripheral and inflamed tissue-residing T- and B-cell populations, ectopic lymphoid tissue neoformation, the characterization of PR3-specific T-cells, properties of ANCA, links between autoimmune disease and infection-triggered pathology, and animal models in AAV.