Granulomatosis with polyangiitis mimicking infective endocarditis in an adolescent male

Sterile Endocarditis and Splenic Infarct: A Rare Masquerading Presentation of Granulomatosis With Polyangiitis in a Patient With Pulmonary Aspergillosis

Granulomatosis with polyangiitis (GPA) is a rare multisystem disease characterized by vasculitis affecting small vessels, resulting in the formation of necrotising granulomata, primarily affecting the lungs, the upper respiratory tract, and kidneys. Almost all patients have upper and lower respiratory involvement; up to 85% of patients with GPA develop kidney disease within two years of diagnosis. Cutaneous, neurological, and ocular manifestations are also seen with varying frequencies. However, cardiac manifestations of the disease are rare and scarcely reported in the literature. Here, we report a case of a 65-year-old female with an initial diagnosis of pulmonary aspergillosis based on the presence of septate hyphae branching at acute angles on lung biopsy and elevated serum galactomannan, who, over the following months, developed a multitude of issues such as myocardial infarction, sterile endocarditis, splenic infarction, and heart block, as well as the challenges faced in establishing a diagnosis and managing its complications.

Cardiac involvement and cardiovascular risk factors in pediatric primary systemic vasculitides

Pediatric primary systemic vasculitides are a complex group of diseases. Vasculitis subgroups are mainly determined according to the size of the predominantly affected vessels. In patients with primary systemic vasculitis, the location of vascular involvement, the size of the vessels, the extent of vascular damage, and the underlying pathology determine the disease phenotype and severity. Cardiac involvement is rare in some pediatric vasculitis, such as IgA vasculitis and polyarteritis nodosa, while it is more common in some others like Kawasaki disease and Takayasu arteritis. On the other hand, chronic inflammation in the setting of systemic vasculitis forms a major cardiovascular risk factor. Accelerated atherosclerosis and the tendency to thrombosis are the main issues determining the cardiovascular risks in pediatric systemic vasculitis. Early diagnosis and treatment are essential in these patients to minimize morbidity and mortality. In this review, we aimed to raise physicians' awareness of cardiac involvement and cardiovascular risks in pediatric patients with primary systemic vasculitis.

ANCA-associated vasculitis with cardiac valve vegetations in two teenage males: two case reports and a literature review

BACKGROUND

Anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis is a term used to describe systemic vasculitides that affect small and medium-sized blood vessels. Granulomatosis with Polyangiitis (GPA), a type of ANCA-associated vasculitis (AAV), is rare in children with an estimated prevalence of 3-4 per million, and even more rare is the manifestation of cardiac abnormalities secondary to ANCA-associated vasculitis in the pediatric population.

CASE PRESENTATION

We discuss the cases of two teenage males who presented with cardiac valvular lesions secondary to GPA in addition to sinus, pulmonary, renal, and cutaneous involvement. These findings of cardiac valvular abnormalities in GPA have rarely been described in the literature in pediatrics. Both patients were treated with rituximab, high-dose methylprednisolone, and therapeutic plasma exchange and showed improvement in their disease manifestations.

CONCLUSIONS

A review of the literature revealed only five pediatric cases of ANCA-associated vasculitis with cardiac manifestations, and interestingly, three of the five had valvular involvement. Subsequent valvular involvement makes obtaining the diagnosis of ANCA-Associated Vasculitis difficult due to concern for underlying infectious endocarditis and can lead to misdiagnosis given the rarity of cardiac involvement in ANCA-associated vasculitis. Routine echocardiogram is not always completed in newly diagnosed AAV, yet cardiac involvement can lead to severe consequences as was seen with our first patient in the form of thromboembolic stroke. We discuss the importance of keeping AAV on the differential when cardiac lesions are present as well as the importance of regular cardiac screening in newly diagnosed patients with AAV, as it is a major factor of cardiac morbidity and mortality in the adult population and can contribute substantially to management decisions.

Predicting bacterial infection risk in patients with ANCA-associated vasculitis in southwest China: development of a new nomogram

OBJECTIVES

The aim of this study was to develop and assess a risk nomogram of bacterial infection in patients with ANCA-associated vasculitis (AAV) in southwest China.

METHOD

We established a prediction model based on a training dataset of 249 AAV patients. The least absolute shrinkage and selection operator (Lasso) was used to screen feature variables. Multivariate logistic regression analysis was used to build a prediction model for feature variables. Nomogram was used to predict the risk of bacterial infection in AAV patients. Receiver operating characteristic (ROC) curve was used to evaluate and verify the prediction accuracy of the model. Calibration and clinical useful range was assessed using calibration curve and decision curve analysis, respectively.

RESULTS

Bactericidal permeability enhancement protein of ANCAs (BPI-ANCAs), procalcitonin (PCT), and white blood cell (WBC) were the characteristic variables in this study. Nomogram showed that positive BPI-ANCAs and PCT had higher positive predictive value for bacterial infection in AAV patients. The area under curve (AUC) of the model was 0.703 (95% confidence interval: 0.640-0.766). In the validation model, the AUC was 0.745 (95% confidence interval: 0.617-0.872). Decision curve analysis showed that the nonadherence nomogram was clinically useful within the threshold probability range of 0.31-0.85.

CONCLUSIONS

Nomogram combined with BPI-ANCAs and PCT has the guiding significance for predicting bacterial infection risk in AAV. As an ANCA-specific autoantibody, BPI-ANCAs is helpful for clinicians to understand the role of specific autoantibodies in the pathogenesis of AAV. Key Points • BPI-ANCAs, PCT, and WBC could predict bacterial infection in AAV patients. • Nomogram showed that positive BPI-ANCAs had a high positive predictive value for bacterial infection in AAV patients.

Infective endocarditis mimicking ANCA-associated vasculitis: does it require immunosuppressive therapy?: A case report and literature review

RATIONALE

In the course of endocarditis, the development of antineutrophil cytoplasmic antibody (ANCA)-mediated disease introduces the dilemma of determining the best treatment approach for immune conditions, whether immunosuppressant therapy should be added to antibiotic treatment has remained controversial.

PATIENT CONCERNS

A 33-year-old man presented with progressive fever lasting for 7 months, and swelling, pain, and purpura in the arms and legs. The patient showed multiple autoantibodies including cytoplasmic ANCA, antiproteinase 3, rheumatoid factor, and anti-beta 2 glycoprotein I. Blood culture was positive for viridans streptococcus, and renal biopsy revealed glomerulonephritis and interstitial nephritis.

DIAGNOSIS

Endocarditis caused by viridans streptococci, ANCA-associated vasculitis, and congenital ventricular septal defect.

INTERVENTIONS

In addition to effective antibiotics, he also received twice intravenous corticosteroids and intravenous immunoglobulin therapy, and a low dose of cyclophosphamide. At last, the patient received congenital ventricular septal defect repair and debridement.

OUTCOMES

The abnormal clinical manifestations, including renal failure and loss of strength, recovered rapidly with corticosteroid therapy in addition to antibiotic treatment. After 6 months without any medications, he remained asymptomatic and was able to live normally.

LESSONS

In this case with endocarditis and ANCA-associated vasculitis, we highlighted the importance of biopsy and immunosuppressive therapy. Histopathologic examination is required for diagnosis and treatment in such case. Identifying patients who have endocarditis and ANCA positivity with vasculitis pathologic features will require corticosteroid/immunosuppressives in addition to the antibiotics therapy.

Analysis of Antineutrophil Cytoplasm Antibody from 118 730 Patients in Tertiary Hospitals in Jiangxi Province, China

BACKGROUND The discovery of antineutrophil cytoplasm antibody (ANCA) makes the early diagnosis of primary vasculitis possible, and also has important guiding significance for the diagnosis and treatment of secondary vasculitis. This study aimed to investigate the clinical significance of ANCA. MATERIAL AND METHODS ANCA was detected by indirect immunofluorescence assay (IIF), and anti-myeloperoxidase (MPO) antibody, and anti-proteinase 3 (PR3) antibody were detected by ELISA. The results were analyzed retrospectively. RESULTS Among 118 730 patients, a total of 5853 (4.93%) were positive for ANCA. In the positive cases, 3.98% were male and 6.33% were female, with significant differences (χ²=123.38, P<0.01). For ANCA, the department with the highest positive rate (15.06%) was the Department of Rheumatology, followed by 7.78% in the Department of Dermatology, 6.79% in the Department of Nephrology, and 5.72% in the Department of Traditional Chinese Medicine (TCM). Anti-PR3 and cANCA were highly specific in primary vasculitis (P<0.01). Anti-MPO and pANCA had high specificity for other autoimmune diseases (P<0.01). CONCLUSIONS ANCA has important guiding significance for vasculitis-related diseases. Therefore, it is important in the diagnosis and treatment of this disease and has value in clinical practice.