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Schmidt WA, Schäfer VS. Diagnosing vasculitis with ultrasound: findings and pitfalls. Ther Adv Musculoskelet Dis 2024; 16:1759720X241251742. [PMID: 38846756 PMCID: PMC11155338 DOI: 10.1177/1759720x241251742] [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: 02/11/2024] [Accepted: 04/10/2024] [Indexed: 06/09/2024] Open
Abstract
Rheumatologists are increasingly utilizing ultrasound for suspected giant cell arteritis (GCA) or Takayasu arteritis (TAK). This enables direct confirmation of a suspected diagnosis within the examination room without further referrals. Rheumatologists can ask additional questions and explain findings to their patients while performing ultrasound, preferably in fast-track clinics to prevent vision loss. Vascular ultrasound for suspected vasculitis was recently integrated into rheumatology training in Germany. New European Alliance of Associations for Rheumatology recommendations prioritize ultrasound as the first imaging tool for suspected GCA and recommend it as an imaging option for suspected TAK alongside magnetic resonance imaging, positron emission tomography and computed tomography. Ultrasound is integral to the new classification criteria for GCA and TAK. Diagnosis is based on consistent clinical and ultrasound findings. Inconclusive cases require histology or additional imaging tests. Robust evidence establishes high sensitivities and specificities for ultrasound. Reliability is good among experts. Ultrasound reveals a characteristic non-compressible 'halo sign' indicating intima-media thickening (IMT) and, in acute disease, artery wall oedema. Ultrasound can further identify stenoses, occlusions and aneurysms, and IMT can be measured. In suspected GCA, ultrasound should include at least the temporal and axillary arteries bilaterally. Nearly all other arteries are accessible except the descending thoracic aorta. TAK mostly involves the common carotid and subclavian arteries. Ultrasound detects subclinical GCA in over 20% of polymyalgia rheumatica (PMR) patients without GCA symptoms. Patients with silent GCA should be treated as GCA because they experience more relapses and require higher glucocorticoid doses than PMR patients without GCA. Scores based on intima-thickness (IMT) of temporal and axillary arteries aid follow-up of GCA, particularly in trials. The IMT decreases more rapidly in temporal than in axillary arteries. Ascending aorta ultrasound helps monitor patients with extracranial GCA for the development of aneurysms. Experienced sonologists can easily identify pitfalls, which will be addressed in this article.
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Affiliation(s)
- Wolfgang A. Schmidt
- Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Lindenberger Weg 19, Berlin 13125, Germany
| | - Valentin S. Schäfer
- Department of Rheumatology and Clinical Immunology, Clinic of Internal Medicine III, University Hospital Bonn, Bonn, Nordrhein-Westfalen, Germany
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Denis G, Espitia O, Allix-Béguec C, Dieval C, Lorcerie F, Gombert B, Pouget-Abadie X, Toquet C, Agard C, Raimbeau A, Gautier G, Goujon JM, Durand G, Thollot-Karolewicz C, Lormeau C, Grados A, Grenot-Mercier A, El-Khoury R, Riche A, Hospital F, Visee S, Auriault ML, Landron C, Martin M, Roncato C. Diagnostic Strategy Using Color Doppler Ultrasound of Temporal Arteries in Patients With High Clinical Suspicion of Giant Cell Arteritis : A Prospective Cohort Study. Ann Intern Med 2024; 177:729-737. [PMID: 38710093 DOI: 10.7326/m23-3417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Giant cell arteritis (GCA) is the most prevalent systemic vasculitis in people older than 50 years. Any delay in diagnosis impairs patients' quality of life and can lead to permanent damage, particularly vision loss. OBJECTIVE To evaluate a diagnostic strategy for GCA using color Doppler ultrasound of the temporal artery as a first-line diagnostic test, temporal artery biopsy (TAB) as a secondary test, and physician expertise as the reference method. DESIGN Prospective multicenter study with a 2-year follow-up. (ClinicalTrials.gov: NCT02703922). SETTING Patients were referred by their general practitioner or ophthalmologist to a physician with extensive experience in GCA diagnosis and management in one of the participating centers: 4 general and 2 university hospitals. PATIENTS 165 patients with high clinical suspicion of GCA, aged 79 years (IQR, 73 to 85 years). INTERVENTION The diagnostic procedure was ultrasound, performed less than 7 days after initiation of corticosteroid therapy. Only ultrasound-negative patients underwent TAB. MEASUREMENTS Bilateral temporal halo signs seen on ultrasound were considered positive. Ultrasound and TAB results were compared with physician-diagnosed GCA based on clinical findings and other imaging. RESULTS Diagnosis of GCA was confirmed in 44%, 17%, and 21% of patients by ultrasound, TAB, and clinical expertise and/or other imaging tests, respectively. Their diagnosis remained unchanged at 1 month, and 2 years for those with available follow-up data. An alternative diagnosis was made in 18% of patients. The proportion of ultrasound-positive patients among patients with a clinical GCA diagnosis was 54% (95% CI, 45% to 62%). LIMITATION Small sample size, no blinding of ultrasound and TAB results, lack of an objective gold-standard comparator, and single diagnostic strategy. CONCLUSION By using ultrasound of the temporal arteries as a first-line diagnostic tool in patients with high clinical suspicion of GCA, further diagnostic tests for patients with positive ultrasound were avoided. PRIMARY FUNDING SOURCE Tender "Recherche CH-CHU Poitou-Charentes 2014."
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Affiliation(s)
- Guillaume Denis
- Department of Internal Medicine and Hematology, Centre Hospitalier Rochefort, Rochefort, France (G.Denis, C.D.)
| | - Olivier Espitia
- Department of Internal and Vascular Medicine, l'Institut du Thorax, INSERM UMR 1087/CNRS UMR 6291, Nantes; and Team III Vascular & Pulmonary Diseases, Nantes Université, CHU Nantes, Nantes, France (O.E., C.A.-B., A.Raimbeau, G.G.)
| | - Caroline Allix-Béguec
- Department of Clinical Research, Centre Hospitalier La Rochelle, La Rochelle, France (C.A.)
| | - Céline Dieval
- Department of Internal Medicine and Hematology, Centre Hospitalier Rochefort, Rochefort, France (G.Denis, C.D.)
| | - Fanny Lorcerie
- Department of Vascular Medicine, Centre Hospitalier Rochefort, Rochefort, France (F.L.)
| | - Bruno Gombert
- Department of Rheumatology, Centre Hospitalier La Rochelle, La Rochelle, France (B.G.)
| | - Xavier Pouget-Abadie
- Department of Internal Medicine and Infectious Diseases, Centre Hospitalier La Rochelle, La Rochelle, France (X.P.-A.)
| | - Claire Toquet
- Department of Pathology, l'Institut du Thorax, INSERM UMR 1087/CNRS UMR 6291, Nantes Université, CHU Nantes, Nantes, France (C.T.)
| | - Christian Agard
- Department of Internal and Vascular Medicine, l'Institut du Thorax, INSERM UMR 1087/CNRS UMR 6291, Nantes; and Team III Vascular & Pulmonary Diseases, Nantes Université, CHU Nantes, Nantes, France (O.E., C.A.-B., A.Raimbeau, G.G.)
| | - Alizée Raimbeau
- Department of Internal and Vascular Medicine, l'Institut du Thorax, INSERM UMR 1087/CNRS UMR 6291, Nantes; and Team III Vascular & Pulmonary Diseases, Nantes Université, CHU Nantes, Nantes, France (O.E., C.A.-B., A.Raimbeau, G.G.)
| | - Giovanni Gautier
- Department of Internal and Vascular Medicine, l'Institut du Thorax, INSERM UMR 1087/CNRS UMR 6291, Nantes; and Team III Vascular & Pulmonary Diseases, Nantes Université, CHU Nantes, Nantes, France (O.E., C.A.-B., A.Raimbeau, G.G.)
| | | | - Géraldine Durand
- Department of Rheumatology, CHU Poitiers, Poitiers, France (G.Durand)
| | | | - Christian Lormeau
- Department of Rheumatology, Centre Hospitalier Niort, Niort, France (C.Lormeau)
| | - Aurélie Grados
- Department of Internal Medicine, Centre Hospitalier Niort, Niort, France (A.G.)
| | - Anne Grenot-Mercier
- Department of Vascular Medicine, Centre Hospitalier Niort, Niort, France (A.G.-M.)
| | - Rony El-Khoury
- Department of Pathology, Centre Hospitalier Niort, Niort, France (R.E.)
| | - Agnès Riche
- Department of Internal Medicine, Centre Hospitalier Angoulême, Angoulême, France (A.Riche)
| | - Florence Hospital
- Department of Vascular Medicine, Centre Hospitalier Angoulême, Angoulême, France (F.H.)
| | - Sebastien Visee
- Department of Pathology, Centre Hospitalier Angoulême, Angoulême, France (S.V.)
| | - Marie-Luce Auriault
- Department of Pathology, Centre Hospitalier La Rochelle, La Rochelle, France (M.-L.A.)
| | - Cédric Landron
- Department of Internal Medicine, CHU Poitiers, Poitiers, France (C.Landron)
| | - Mickaël Martin
- Department of Internal Medicine, INSERM U1313, Poitiers University, Poitiers University Hospital, Poitiers, France (M.M.)
| | - Christophe Roncato
- Department of Vascular Medicine, Centre Hospitalier La Rochelle, La Rochelle, France (C.R.)
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Dejaco C, Ramiro S, Bond M, Bosch P, Ponte C, Mackie SL, Bley TA, Blockmans D, Brolin S, Bolek EC, Cassie R, Cid MC, Molina-Collada J, Dasgupta B, Nielsen BD, De Miguel E, Direskeneli H, Duftner C, Hočevar A, Molto A, Schäfer VS, Seitz L, Slart RHJA, Schmidt WA. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice: 2023 update. Ann Rheum Dis 2024; 83:741-751. [PMID: 37550004 DOI: 10.1136/ard-2023-224543] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/18/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVES To update the EULAR recommendations for the use of imaging modalities in primary large vessel vasculitis (LVV). METHODS A systematic literature review update was performed to retrieve new evidence on ultrasound, MRI, CT and [18F]-fluorodeoxyglucose positron emission tomography (FDG-PET) for diagnosis, monitoring and outcome prediction in LVV. The task force consisted of 24 physicians, health professionals and patients from 14 countries. The recommendations were updated based on evidence and expert opinion, iterating until voting indicated consensus. The level of agreement was determined by anonymous votes. RESULTS Three overarching principles and eight recommendations were agreed. Compared to the 2018 version, ultrasound is now recommended as first-line imaging test in all patients with suspected giant cell arteritis, and axillary arteries should be included in the standard examination. As an alternative to ultrasound, cranial and extracranial arteries can be examined by FDG-PET or MRI. For Takayasu arteritis, MRI is the preferred imaging modality; FDG-PET, CT or ultrasound are alternatives. Although imaging is not routinely recommended for follow-up, ultrasound, FDG-PET or MRI may be used for assessing vessel abnormalities in LVV patients with suspected relapse, particularly when laboratory markers of inflammation are unreliable. MR-angiography, CT-angiography or ultrasound may be used for long-term monitoring of structural damage, particularly at sites of preceding vascular inflammation. CONCLUSIONS The 2023 EULAR recommendations provide up-to-date guidance for the role of imaging in the diagnosis and assessment of patients with LVV.
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Affiliation(s)
- Christian Dejaco
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
- Department of Rheumatology, Teaching Hospital of the Paracelsius Medical University, Brunico Hospital (ASAA-SABES), Brunico, Italy
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Milena Bond
- Department of Rheumatology, Teaching Hospital of the Paracelsius Medical University, Brunico Hospital (ASAA-SABES), Brunico, Italy
| | - Philipp Bosch
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
| | - Cristina Ponte
- Department of Rheumatology, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal
- Rheumatology Research Unit, Instituto de Medicina Molecular, Lisboa, Portugal
| | - Sarah Louise Mackie
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Thorsten A Bley
- Diagnostic and Interventional Radiology, University Medical Center, Wuerzburg, Germany
| | - Daniel Blockmans
- Clinical Department of General Internal Medicine Department, Research Department of Microbiology and Immunology, Laboratory of Clinical Infectious and Inflammatory Disorders, University Hospitals Leuven, Leuven, Belgium
- General Internal Medicine Department, Universitair Ziekenhuis Gasthuisberg, Leuven, Belgium
| | - Sara Brolin
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Ertugrul Cagri Bolek
- Department of Internal Medicine, Division of Rheumatology, Hacettepe Universitesi Tip Fakultesi, Ankara, Turkey
| | | | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona. Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Juan Molina-Collada
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Bhaskar Dasgupta
- Rheumatology, Southend University Hospital NHS Foundation Trust, Basildon, UK
- Anglia Ruskin University, Chelmsford, UK
| | - Berit Dalsgaard Nielsen
- Department of Rheumatology, Aarhus Universitetshospital, Aarhus, Denmark
- Department of Medicine, Regional Hospital Horsens, Horsens, Denmark
| | - Eugenio De Miguel
- Department of Rheumatology, La Paz University Hospital, Madrid, Spain
| | - Haner Direskeneli
- Department of Internal Medicine, Division of Rheumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Christina Duftner
- Department of Internal Medicine, Clinical Division of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | - Alojzija Hočevar
- Department of Rheumatology, University Medical Centre, Ljubljana, Slovenia
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Anna Molto
- Department of Rheumatology, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
- INSERM (U1153) Center of Research in Epidemiology and Statistics (CRESS), Université Paris-Cité, Paris, France
| | - Valentin Sebastian Schäfer
- Clinic of Internal Medicine III, Section Rheumatology and Clinical Immunology, University Hospital Bonn, Bonn, Germany
| | - Luca Seitz
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Riemer H J A Slart
- Medical Imaging Centre, Department of Nuclear Medicine and Molecular Imaging, University Medical Center, Groningen, The Netherlands
- Department of Biomedical Photonic Imaging, Universiteit Twente, Enschede, The Netherlands
| | - Wolfgang A Schmidt
- Department of Rheumatology, Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Berlin, Germany
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Seitz L, Bucher S, Bütikofer L, Maurer B, Bonel HM, Wagner F, Lötscher F, Seitz P. Diffusion-weighted magnetic resonance imaging for the diagnosis of giant cell arteritis: a comparison with T1-weighted black-blood imaging. Rheumatology (Oxford) 2024; 63:1403-1410. [PMID: 37555808 DOI: 10.1093/rheumatology/kead401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/19/2023] [Accepted: 07/18/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVES To investigate the diagnostic performance of diffusion-weighted imaging (DWI) of the superficial cranial arteries in the diagnosis of GCA. METHODS Retrospectively, 156 patients with clinically suspected GCA were included. A new 4-point ordinal DWI rating scale was developed. A post-contrast, fat-suppressed, T1-weighted 'black-blood' sequence (T1-BB) was rated for comparison. Ten arterial segments were assessed: common superficial temporal arteries, temporal and parietal branches, occipital and posterior auricular arteries bilaterally. The expert clinical diagnosis after ≥6 months of follow-up was the diagnostic reference standard. Diagnostic accuracy was evaluated for different rating methods. RESULTS The study cohort consisted of 87 patients with and 69 without GCA. For DWI, the area under the curve was 0.90. For a cut-off of ≥2 consecutive pathological slices, DWI showed a sensitivity of 75.9%, a specificity of 94.2% and a positive likelihood ratio of 13.09. With a cut-off of ≥3 consecutive pathological slices, sensitivity was 70.1%, specificity was 98.6% and the positive likelihood ratio was 48.38. For the T1-BB, values were 88.5%, 88.4% and 7.63, respectively. The inter-rater analysis for DWI with a cut-off of ≥2 pathological slices showed a kappa of 1.00 on the patient level and 0.85 on the arterial segment level. For the T1-BB the kappa was 0.78 and 0.79, respectively. CONCLUSION DWI of the superficial cranial arteries demonstrates a good diagnostic accuracy and reliability for the diagnosis of GCA. DWI is widely available and can be used immediately in clinical practice for patients with suspected GCA.
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Affiliation(s)
- Luca Seitz
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Susana Bucher
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | - Britta Maurer
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Harald M Bonel
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
- Campusradiologie, Lindenhofgruppe, Bern, Switzerland
| | - Franca Wagner
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Fabian Lötscher
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Pascal Seitz
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
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Seitz P, Lötscher F, Bucher S, Bütikofer L, Maurer B, Hakim A, Seitz L. Ultrasound intima-media thickness cut-off values for the diagnosis of giant cell arteritis using a dual clinical and MRI reference standard and cardiovascular risk stratification. Front Med (Lausanne) 2024; 11:1389655. [PMID: 38654833 PMCID: PMC11037081 DOI: 10.3389/fmed.2024.1389655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
Objectives To derive segmental cut-off values and measures of diagnostic accuracy for the intima-media thickness of compressed temporal artery segments for the diagnosis of giant cell arteritis (GCA) on the patient level. To examine the influence of cardiovascular risk. Methods Retrospectively, patients evaluated for GCA with an ultrasound of the temporal arteries and an MRI of the head, including a T1-fatsat-black blood (T1-BB) sequence, were identified and classified based on cardiovascular risk and a dual reference standard of T1-BB on the segmental level and the clinical diagnosis on the patient level. Intima-media thickness of the common superficial temporal artery (CSTA), frontal and parietal branches (FB, PB) were measured by compression technique. Statistically and clinically optimal (specificity of approx. 90% for the patient level) cut-offs were derived. Diagnostic accuracy was evaluated on the patient level. Results The population consisted of 144 patients, 74 (51.4%) with and 70 (48.6%) without GCA. The statistically optimal cut-offs were 0.86 mm, 0.68 mm and 0.67 mm for the CSTA, the FB and PB, respectively. On the patient level sensitivity and specificity were 86.5 and 81.4%. Clinically optimal cut-offs were 1.01 mm, 0.82 mm and 0.69 mm and showed a sensitivity of 79.7% and a specificity of 90.0%. For patients without high cardiovascular risk, statistically optimal cut-offs showed a sensitivity of 89.6% and a specificity of 90.5%. Conclusion Newly derived ultrasound intima-media thickness cut-offs with a dual reference standard show high diagnostic accuracy on the patient level for the diagnosis of GCA, particularly in patients without high cardiovascular risk.
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Affiliation(s)
- Pascal Seitz
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Fabian Lötscher
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Susana Bucher
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Lukas Bütikofer
- CTU Bern, Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Britta Maurer
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Arsany Hakim
- University Institute of Interventional and Diagnostic Neuroradiology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Luca Seitz
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
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Sixdorf U, Märker-Hermann E. [Polyarteritis nodosa and Kawasaki syndrome : Vasculitis predominantly of medium size and small vessels]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:122-128. [PMID: 38168826 DOI: 10.1007/s00108-023-01637-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/05/2024]
Abstract
Polyarteritis nodosa (PAN) and Kawasaki syndrome (KS) are rare forms of primary vasculitis with heterogeneous manifestations and courses of the disease. According to the Chapel Hill Consensus Conference 2012 they belong to the vasculitis of medium size vessels. In contrast to microscopic polyangiitis (MPA), PAN and KS do not affect microscopic vessels such as arterioles, venules or capillaries and are not associated with antineutrophil cytoplasmic antibodies (ANCA). The diagnostics are based on the typical constellation of clinical symptoms, on angiographic findings, the exclusion of other differential diagnoses and, in the case of PAN, in the histopathological confirmation. The therapeutic options of KS in childhood and PAN in adults and children, which are dependent on the severity and the prognosis, are presented.
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Affiliation(s)
- Ulrike Sixdorf
- Klinik Innere Medizin IV (Geriatrie und Rheumatologie), Helios Dr. Horst Schmidt Kliniken Wiesbaden GmbH, Ludwig Erhard-Str. 100, 65199, Wiesbaden, Deutschland.
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Mohammadzadeh A, Houshmand G, Pouraliakbar H, Soltani Z, Salehabadi G, Azimi A, Shabanian R. Coronary artery involvement in a patient with IgG4-related disease. Radiol Case Rep 2023; 18:3699-3703. [PMID: 37609068 PMCID: PMC10440403 DOI: 10.1016/j.radcr.2023.07.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 06/10/2023] [Accepted: 07/23/2023] [Indexed: 08/24/2023] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a chronic fibro-inflammatory disorder of obscure etiology characterized by significant infiltration of IgG4-positive plasma cells toward several organs. Coronary artery involvement is rarely seen in IgG4-RD patients; thereby, we aim to outline the noninvasive imaging findings of this rare case. Cardiac magnetic resonance (CMR) and coronary computed tomography angiography (CCTA) from a 15-year-old female diagnosed with IgG4-RD via histopathological assessment of orbital biopsy, were analyzed. CMR showed a severely reduced left ventricular ejection fraction and akinesia of the basal to mid-lateral, anterior, and septal walls. Inflammation of the basal to apical lateral wall and subendocardial infarction of the basal to apical lateral and mid inferoseptal walls were also evident. CCTA findings showed stenosis in branches of the left main artery (LM), left anterior descending artery (LAD), and right coronary artery (RCA), aortitis, and aortic wall thickening. After courses of proper treatment with prednisolone, Cellcept, and adalimumab, follow-up CMR showed significant improvement in LV systolic function and resolution of inflammation. Although IgG4-RD is an uncommon cause of coronary artery disease, it can cause lethal complications such as myocardial infarction. Hence, clinicians should be aware of cardiac complications in these patients.
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Affiliation(s)
- Ali Mohammadzadeh
- Rajaie Cardiovascular Medical and Research Center, Iran University of medical sciences, Tehran, Iran
| | - Golnaz Houshmand
- Rajaie Cardiovascular Medical and Research Center, Iran University of medical sciences, Tehran, Iran
| | - Hamidreza Pouraliakbar
- Rajaie Cardiovascular Medical and Research Center, Iran University of medical sciences, Tehran, Iran
| | - Zeinab Soltani
- Rajaie Cardiovascular Medical and Research Center, Iran University of medical sciences, Tehran, Iran
| | - Ghazaleh Salehabadi
- Rajaie Cardiovascular Medical and Research Center, Iran University of medical sciences, Tehran, Iran
| | - Amir Azimi
- Rajaie Cardiovascular Medical and Research Center, Iran University of medical sciences, Tehran, Iran
| | - Reza Shabanian
- Children`s Medical Center, Tehran University of Medical Sciences, Tehran, Iran
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Ma J, Song W, Xu H, Zhong Z, Huyan Y, Liu S. Pulmonary endarterectomy in patients with occlusive isolated pulmonary vasculitis. Eur J Med Res 2023; 28:269. [PMID: 37550701 PMCID: PMC10405401 DOI: 10.1186/s40001-023-01239-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/19/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Isolated pulmonary vasculitis (IPV) is a rare, insidious, and localized inflammatory disease affecting the pulmonary arteries, often leading to severe luminal obstruction. The prognosis for patients with occlusive IPV is poor, and there is currently a lack of effective treatments. The objective of this study was to evaluate the performance of pulmonary endarterectomy (PEA) as a treatment for occlusive IPV. METHODS This single-center retrospective analysis included patients who received PEA for occlusive IPV between January 2018 and June 2022. Clinical characteristics and hemodynamic parameters were evaluated at baseline and follow-up. RESULTS Among 114 consecutive patients who underwent PEA, occlusive IPV was identified in 7 patients. Two patients underwent bilateral PEA for the involvement of both pulmonary arteries. Patch angioplasty was performed to treat four severe constrictions. One patient died from residual pulmonary hypertension after limited PEA of a transmural vascular lesion. In addition, no obvious surgical complications were observed. Three months after PEA, a substantial relief in symptoms was achieved. Also, there is a decrease in the mean pulmonary artery pressure (median 33 [20-48] mmHg before versus median 21 [16-26] mmHg after; P < 0.018) and pulmonary arterial resistance (median 234 [131-843] dyn.s.cm-5 versus median 180 [150-372] dyn.s.cm-5; P = 0.310). Three patients experienced a relapse of restenosis of the treated arteries within a 6-month follow-up period, despite daily oral prednisolone administration. They were treated with balloon pulmonary angioplasty of both the main pulmonary arteries and branches. CONCLUSIONS PEA is a valuable choice for treating occlusive IPV, with notable hemodynamic and clinical advantages. To increase long-term vascular patency, complete management should be optimized.
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Affiliation(s)
- Jiexu Ma
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Beijing, 100037, China
| | - Wu Song
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Beijing, 100037, China
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan, 430022, China
| | - Hang Xu
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Beijing, 100037, China
| | - ZhaoJi Zhong
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Beijing, 100037, China
| | - Yige Huyan
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Beijing, 100037, China
| | - Sheng Liu
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Beijing, 100037, China.
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