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Ambrogi E, Cavazza A, Smith ML, Graziano P. Pulmonary pathology in vasculitis. Pathologica 2024; 116:93-103. [PMID: 38767542 PMCID: PMC11138764 DOI: 10.32074/1591-951x-988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/01/2024] [Indexed: 05/22/2024] Open
Abstract
Pulmonary involvement is frequent in vasculitis, particularly in ANCA-associated small vessel vasculitis. Laboratory and radiological data alone are often sufficient to confirm the clinical hypothesis, but sometimes the pathologist plays a crucial role in the differential diagnosis and the patient's management. In this review, the pathologic features of pulmonary vasculitis and the pathologist's role in this field are illustrated.
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Affiliation(s)
- Elisa Ambrogi
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, Italy
| | | | - Maxwell L. Smith
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Paolo Graziano
- Department of Radiology, Oncology and Pathology Sciences, Sapienza, University of Rome, Italy
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2
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Muacevic A, Adler JR, Takeno Y, Miyazaki K, Tokunaga Y, Hiramatsu K, Kadota JI. Mycobacterium avium Complex Lung Disease Complicated With Antiglomerular Basement Membrane Disease: A Case Report. Cureus 2022; 14:e32192. [PMID: 36620803 PMCID: PMC9811237 DOI: 10.7759/cureus.32192] [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] [Accepted: 12/04/2022] [Indexed: 12/12/2022] Open
Abstract
While both Mycobacterium avium complex (MAC) lung diseases and antiglomerular basement membrane (anti-GBM) antibody disease may cause hemoptysis, no case presenting hemoptysis having both diseases has been reported. A woman in her 80s was admitted due to hemoptysis with acute respiratory failure. MAC was isolated from her sputum, and a positive report for anti-GBM antibody was confirmed in screening for hematuria. This patient has been successfully treated with systemic corticosteroid therapy followed by combination chemotherapy against MAC. Although anti-GBM disease is a rare condition, screening might be recommended in case of uncontrollable hemoptysis as MAC lung disease with hematuria.
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Abstract
Since the first clinicopathologic description by Ernest Goodpasture of a patient whom he considered to have died of influenza in 1919, substantial progress has been made in our knowledge of anti-glomerular basement membrane disease. This has led to a significant decrease in the morbidity and mortality associated with this disease. In this paper, we aim to review the literature that has enhanced our understanding of classic anti-glomerular basement membrane disease and its clinic-pathologic variants in the key areas of immunopathogenesis and histopathology. We also summarize varied clinical presentations and therapeutic strategies.
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4
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Pulmonary Imaging Findings of Vasculitis. CURRENT PULMONOLOGY REPORTS 2020. [DOI: 10.1007/s13665-020-00263-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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5
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Abstract
Systemic vasculitides frequently affect the pulmonary vasculature. As the signs and symptoms of pulmonary vasculitis are variable and nonspecific, diagnosis and treatment represent a real challenge. Vasculitides should be given consideration, as these diseases present severe manifestations of rapidly progressing pulmonary disease. Examining other organs usually affected by vasculitides (e.g., the skin and kidneys) and determining autoantibody levels are essential to a better management of the disease. A radiological study would also contribute to establishing a diagnosis. The lungs are commonly involved in small-vessel vasculitis, anti-glomerular basement membrane disease, and vasculitides associated with antineutrophil cytoplasmic antibodies. Associated life-threatening diffuse alveolar haemorrhages and irreversible damage to other organs-usually the kidneys-are severe complications that require early diagnosis. Vasculitides are rare diseases that affect multiple organs. An increasing number of treatments-including biological agent-based therapies-requiring cooperation between specialists and centers have become available in the recent years. In the same way, clinicians should be familiar with the complications associated with immunosuppressive therapies.
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Affiliation(s)
| | | | | | | | | | - Luis Valdés
- Interdisciplinary Research Group in Pneumology, Institute of Sanitary Research of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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6
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Batra K, Chamarthy M, Chate RC, Jordan K, Kay FU. Pulmonary vasculitis: diagnosis and endovascular therapy. Cardiovasc Diagn Ther 2018; 8:297-315. [PMID: 30057877 DOI: 10.21037/cdt.2017.12.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Pulmonary vasculitides are caused by a heterogeneous group of diseases with different clinical features and etiologies. Radiologic manifestations depend on the predominant type of vessel involved, which are grouped into large, medium, or small-sized vessels. Diagnosing pulmonary vasculitides is a challenging task, and radiologists play an important role in their management by providing supportive evidence for diagnosis and opportunities for minimally invasive therapy. This paper aims to present a practical approach for understanding the vasculitides that can affect the pulmonary vessels and lungs. We will describe and illustrate the main radiologic findings, discussing opportunities for minimally invasive treatment.
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Affiliation(s)
- Kiran Batra
- UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Rodrigo Caruso Chate
- Hospital Israelita Albert Einstein and Instituto to Coração HCFMUSP, Sao Paulo, Brazil
| | - Kirk Jordan
- UT Southwestern Medical Center, Dallas, TX, USA
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7
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Poststreptococcal Glomerulonephritis With Unusual Lung Involvement. J Clin Rheumatol 2018; 25:e87-e89. [PMID: 29664821 DOI: 10.1097/rhu.0000000000000734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Abstract
A wide variety of insults can produce acute lung damage, inclusive of those that injure the lungs directly. The clinical syndrome of acute onset respiratory distress, dyspnea, and bilateral infiltrates is referred to as acute respiratory distress syndrome. The histologic counterpart of acute respiratory distress syndrome is diffuse alveolar damage, classically characterized by hyaline membranes. Other histologic features of acute lung injury include intraalveolar fibrin, organization, interstitial edema, and reactive pneumocytes. Diffuse alveolar damage and other histologic features of acute lung injury are nonspecific as to etiology, and once identified require the pathologist to search the biopsy for further features that may help identify a specific etiology. This chapter reviews the temporal sequence of acute lung injury and explores the large variety of specific etiologic causes with emphasis on helpful histologic features to identify.
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Abstract
There is increased awareness of smoking-related lung diseases other than lung cancer and chronic obstructive pulmonary disease. Concurrently, there is general acceptance that there is difficulty in establishing a specific diagnosis of smoking-related interstitial lung disease (ILD), as many patients may not undergo biopsy to facilitate a specific histopathologic diagnosis. Cases that do proceed to biopsy may demonstrate multiple abnormalities, and histologic overlap between different disease processes may confound the picture. This review outlines the key aspects of smoking-related lung disease, including entities secondary to smoking-related lung inflammation such as respiratory bronchiolitis-ILD, desquamative idiopathic pneumonia, and pulmonary Langerhans cell histiocytosis, as well as chronic fibrosing lung diseases strongly associated with cigarette smoke including idiopathic pulmonary fibrosis, combined pulmonary fibrosis and emphysema, nonspecific interstitial pneumonia, and rheumatoid arthritis-ILD. The focus will be on incorporation of clinical findings, key pulmonary function testing parameters, high-resolution computer tomography (HRCT) findings, and pathologic correlates in refining the differential diagnosis and differentiating between the various entities.
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Mahmoud S, Ghosh S, Farver C, Lempel J, Azok J, Renapurkar RD. Pulmonary Vasculitis: Spectrum of Imaging Appearances. Radiol Clin North Am 2016; 54:1097-1118. [PMID: 27719978 DOI: 10.1016/j.rcl.2016.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Pulmonary vasculitis is a relatively uncommon disorder, usually manifesting as part of systemic vasculitis. Imaging, specifically computed tomography, is often performed in the initial diagnostic workup. Although the findings in vasculitis can be nonspecific, they can provide important clues in the diagnosis, and guide the clinical team toward the right diagnosis. Radiologists must have knowledge of common and uncommon imaging findings in various vasculitides. Also, radiologists should be able to integrate the clinical presentation and laboratory test findings together with imaging features, so as to provide a meaningful differential diagnosis.
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Affiliation(s)
- Shamseldeen Mahmoud
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Subha Ghosh
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Carol Farver
- Department of Pathology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Jason Lempel
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Joseph Azok
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Rahul D Renapurkar
- Section of Thoracic Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Section of Cardiovascular Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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11
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[Vasculitis: New nomenclature of the Chapel Hill consensus conference 2012]. Z Rheumatol 2015; 73:823-33; quiz 834-5. [PMID: 25269877 DOI: 10.1007/s00393-014-1477-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Within the last years, many advances have been made in the understanding of the etiopathology of vasculitis as well as of different disease courses. The revised 2012 Chapel Hill consensus conference (CHCC) nomenclature reflects current knowledge on the etiopathology in addition to the descriptive principles of vessel size and types of inflammation. The anti-neutrophil cytoplasmic antibody (ANCA)-associated forms of vasculitis have been separated as a group, as opposed to immune complex small vessel vasculitis. When consensus was achieved eponyms have been replaced by systematic names, such as granulomatosis with polyangiitis (Wegener's granulomatosis) or eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Moreover, clinically important but less well-known types of vasculitis have now been included in the CHCC nomenclature. This article presents the changes and summarizes the results of important new articles on the clinical picture and morphology of vasculitis.
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12
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[Vasculitis. New nomenclature of the Chapel Hill consensus conference 2012]. DER PATHOLOGE 2014; 34:569-79; quiz 580-1. [PMID: 24154756 DOI: 10.1007/s00292-013-1796-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In recent years, many advances have been made in our understanding of vasculitis etiopathology as well as of different disease courses. The revised Chapel Hill Consensus Conference (CHCC) 2012 nomenclature reflects current knowledge about etiopathology, in addition to the descriptive principles of vessel size and type of inflammation. Anti-neutrophil cyptoplasmic antibody (ANCA)-associated vasculitides have been classified as a separate group, as opposed to immune complex small vessel vasculitis. In cases where consensus was achieved, eponyms have been replaced by systematic names, such as granulomatosis with polyangiitis (Wegener's) or eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Moreover, clinically important but less well-known types of vasculitis have now been included in the CHCC nomenclature. This article presents the changes, focussing on those types that are relevant to the histopathologist, and summarizes the results of important new articles on morphology and clinical picture of vasculitis.
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Dellaripa PF, Fischer A, Flaherty KR. Pulmonary Manifestations of Vasculitis. PULMONARY MANIFESTATIONS OF RHEUMATIC DISEASE 2014. [PMCID: PMC7120293 DOI: 10.1007/978-1-4939-0770-0_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Paul F. Dellaripa
- Harvard Medical School, Department of Medicine, Division of Rheumatology Brigham and Women’s Hospital, Boston, Massachusetts USA
| | - Aryeh Fischer
- Division of Rheumatology, Autoimmune and Interstitial Lung Disease Program, Department of Medicine, National Jewish Health, Denver, Colorado USA
| | - Kevin R. Flaherty
- Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine, University of Michigan Medical School, Ann Arbor, Michigan USA
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14
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Wilfong EM, Seo P. Vasculitis in the intensive care unit. Best Pract Res Clin Rheumatol 2013; 27:95-106. [PMID: 23507060 DOI: 10.1016/j.berh.2013.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 01/02/2013] [Indexed: 10/27/2022]
Abstract
The systemic vasculitides are a diverse set of diseases linked by the presence of blood-vessel inflammation and are often associated with life-threatening or critical complications, including glomerulonephritis, diffuse alveolar haemorrhage, pulmonary arterial hypertension and airway compromise. The protean manifestations of the systemic vasculitides make them challenging to diagnose. Early recognition, however, is crucial to improving outcomes. This article serves as an introduction to these complex diseases, reviewing the manifestations of systemic vasculitis that may be encountered in an intensive care setting, and outlines an overall approach to their treatment.
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Affiliation(s)
- Erin M Wilfong
- Johns Hopkins University School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA.
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Traclet J, Lazor R, Cordier JF, Cottin V. Hémorragie intra-alvéolaire. Rev Med Interne 2013; 34:214-23. [DOI: 10.1016/j.revmed.2012.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 06/15/2012] [Accepted: 08/01/2012] [Indexed: 12/22/2022]
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Jennette JC, Falk RJ, Bacon PA, Basu N, Cid MC, Ferrario F, Flores-Suarez LF, Gross WL, Guillevin L, Hagen EC, Hoffman GS, Jayne DR, Kallenberg CGM, Lamprecht P, Langford CA, Luqmani RA, Mahr AD, Matteson EL, Merkel PA, Ozen S, Pusey CD, Rasmussen N, Rees AJ, Scott DGI, Specks U, Stone JH, Takahashi K, Watts RA. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. ARTHRITIS AND RHEUMATISM 2013; 65:1-11. [PMID: 23045170 DOI: 10.1002/art.37715] [Citation(s) in RCA: 3942] [Impact Index Per Article: 358.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 09/18/2012] [Indexed: 02/06/2023]
Affiliation(s)
- J C Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC 27599, USA.
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Martín-Suñé N, Ríos-Blanco JJ. Pulmonary affectation of vasculitis. Arch Bronconeumol 2012; 48:410-8. [PMID: 22682604 DOI: 10.1016/j.arbres.2012.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2012] [Accepted: 04/09/2012] [Indexed: 10/28/2022]
Abstract
Respiratory tract affectation is frequent in some types of vasculitis, fundamentally in those associated with anti-neutrophil cytoplasmic antibodies (ANCA). The clinical, radiological and histopathological presentation is also heterogeneous and conditions the evolution. It is therefore necessary to establish an early diagnosis based on the symptoms because, thanks to new treatments, and despite them being potentially serious diseases, their prognosis has improved considerably in recent years. The present paper updates the diagnosis and the new therapeutic options for pulmonary vasculitis.
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Abstract
Goodpasture's disease, or anti-glomerular basement membrane (anti-GBM) disease, is a systemic autoimmune disorder defined by anti-GBM antibody-mediated damage (mainly immunoglobulin G-1) resulting in progressive crescentic glomerulonephritis and, frequently, diffuse pulmonary alveolar hemorrhage. It may be regarded as a "conformeropathy" where the quaternary structure of the α345NC1 hexamer that constitutes GBM undergoes a conformational change, exposing pathogenic epitopes on the α3 and α5 chains, eliciting a pathogenic autoantibody anti-GBM response. Goodpasture's disease accounts for 20% of all patients presenting with a pulmonary-renal syndrome and may be associated with detectable perinuclear antineutrophil cytoplasmic autoantibody positivity in up to a third of patients. Associated triggers may include tobacco smoking, hydrocarbon solvent exposure, and cocaine abuse. Cough, hemoptysis, and dyspnea with fatigue are the commonest presenting features. It is critical to rapidly distinguish Goodpasture's disease from other causes of pulmonary-renal syndromes such as Wegener's granulomatosis. Early and intensive treatment with plasmapheresis and immunosuppression with systemic corticosteroids pending results of diagnostic testing, and later cyclophosphamide, is often beneficial, with 90% of patients surviving the acute presentation of Goodpasture's disease. The need for hemodialysis on initial presentation, a serum creatinine >5 mg/dL, and 50% to 100% crescents on renal biopsy, portend the necessity of long-term hemodialysis. Further elucidation of the molecular pathobiology of Goodpasture's disease, particularly the regulation of involved antigen-specific T cells, may improve early diagnosis, treatment, and outcomes in this rare but potentially lethal autoimmune disorder.
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Abstract
The presence of pulmonary vasculitis can be suggested by a clinical presentation that includes diffuse pulmonary hemorrhage, acute glomerulonephritis, chronic refractory sinusitis or rhinorrhea, imaging findings of nodules or cavities, mononeuritis multiplex, multisystemic disease, and palpable purpura. Serologic tests, including the use of cytoplasmic antineutrophil cytoplasmic antibody (ANCA) and perinuclear ANCA, are performed for the differential diagnosis of the diseases. A positive cytoplasmic ANCA test result is specific enough to make a diagnosis of ANCA-associated granulomatous vasculitis if the clinical features are typical. Perinuclear ANCA positivity raises the possibility of Churg-Strauss syndrome or microscopic polyangiitis. Imaging findings of pulmonary vasculitis are diverse and often poorly specific. The use of a pattern-based approach to the imaging findings may help narrow the differential diagnosis of various pulmonary vasculitides. Integration of clinical, laboratory, and imaging findings is mandatory for making a reasonably specific diagnosis.
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Affiliation(s)
- Man Pyo Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul 135-710, Korea
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22
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Benson A, Schwarz M. A 26-year-old woman with recurrent hemoptysis and a sleep disturbance. Chest 2009; 134:1325-1331. [PMID: 19059964 DOI: 10.1378/chest.08-1410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
| | - Marvin Schwarz
- University of Colorado Health Sciences Center, Denver, CO
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23
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Sung HY, Lim CH, Shin MJ, Kim BS, Kim YO, Song HC, Kim SY, Choi EJ, Chang YS, Bang BK. A case of post-streptococcal glomerulonephritis with diffuse alveolar hemorrhage. J Korean Med Sci 2007; 22:1074-8. [PMID: 18162726 PMCID: PMC2694628 DOI: 10.3346/jkms.2007.22.6.1074] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Acute post-streptococcal glomerulonephritis (PSGN) is characterized by an abrupt onset of edema, hypertension, and hematuria. Life-threatening diffuse alveolar hemorrhage (DAH) is rarely associated with acute PSGN. There have been only two reported cases worldwide, and no case has been reported previously in Korea. Here, we present a patient who clinically presented with pulmonary-renal syndrome; the renal histology revealed post-infectious glomerulonephritis of immune complex origin. A 59-yr-old woman was admitted with oliguria and hemoptysis two weeks after pharyngitis. Renal insufficiency rapidly progressed, and respiratory distress developed. Chest radiography showed acute progressive bilateral pulmonary infiltrates. The clinical presentation suggested DAH with PSGN. Three days after treatment with high-dose steroids, the respiratory distress and pulmonary infiltrates resolved. Electron microscopy of a renal biopsy specimen sample revealed diffuse proliferative glomerulonephritis with characteristic subendothelial deposits of immune complex (''hump''). The renal function of the patient was restored, and the serum creatinine level was normalized after treatment.
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Affiliation(s)
- Hye Young Sung
- Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea
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24
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Nicholas A. K, Jacques P. B. Immune‐Mediated Diseases Involving Basement Membranes. CURRENT TOPICS IN MEMBRANES 2005. [DOI: 10.1016/s1063-5823(05)56011-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Magro CM, Morrison C, Pope-Harman A, Rothrauff SK, Ross P. Direct and indirect immunofluorescence as a diagnostic adjunct in the interpretation of nonneoplastic medical lung disease. Am J Clin Pathol 2003; 119:279-89. [PMID: 12580000 DOI: 10.1309/ehuq-hw6k-0g41-e0dx] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Fresh open lung biopsy material from 57 patients was incubated with fluoresceinated complement and immunoglobulin antisera. An indirect immunofluorescent assay using neonatal lung as substrate was conducted as well. Direct immunofluorescent patterns could be categorized into interalveolar septal capillary deposition, large vessel wall localization, alveolar basement membrane localization, or a pauci-immune immunofluorescence pattern. With respect to the septal capillary pattern, endothelial cell decoration was seen with scleroderma, mixed connective tissue disease, anti-Ro-associated lupus erythematosus, dermatomyositis, humoral allograft rejection, and patients with isolated pulmonary fibrosis in whom autoantibodies were established, including antiphospholipid antibodies. A similar pattern of endothelial cell staining was seen in these cases via the indirect assay. Granular mural septal capillary deposition was seen in the aforesaid settings along with rheumatoid factor-positive rheumatoid arthritis, type II cryofibrinogenemia, and mixed cryoglobulinemia and, in some cases, light microscopically corresponded to a neutrophilic capillaritis. Isolated vascular IgA corresponded with rheumatoid arthritis corresponding to IgA-specific antiendothelial cell antibodies, celiac disease-associated pulmonary hemorrhage, Schönlein-Henoch purpura and with IgA antiphospholipid antibodies. Alveolar wall deposition was seen with anti-glomerular basement membrane disease.
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Affiliation(s)
- Cynthia M Magro
- Department of Pathology, Ohio State University Medical Center, Columbus, USA
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Magro CM, Morrison C, Pope-Harman A, Rothrauff SK, Ross P. Direct and Indirect Immunofluorescence as a Diagnostic Adjunct in the Interpretation of Nonneoplastic Medical Lung Disease. Am J Clin Pathol 2003. [DOI: 10.1309/ehuqhw6k0g41e0dx] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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27
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Rodriguez W, Hanania N, Guy E, Guntupalli J. Pulmonary-renal syndromes in the intensive care unit. Crit Care Clin 2002; 18:881-95, x. [PMID: 12418445 DOI: 10.1016/s0749-0704(02)00029-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Renal disease associated with pulmonary hemorrhage is seen in a variety of clinical disorders and is a common cause of admission to intensive care units. Recent advances in the understanding of the pathogenesis of these disorders have improved the therapeutic options significantly and have favorably influenced the course of many of these disorders. This article discusses rheumatologic diseases that involve both the kidney and lungs, with emphasis on pathogenesis and therapeutic options. Common pulmonary-renal syndromes including anti-glomerular basement membrane disease and anti-neutrophil cytoplasmic autoantibodies-associated vasculitis.
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Affiliation(s)
- William Rodriguez
- Division of Renal Diseases and Hypertension, Department of Internal Medicine, University of Texas Medical School, 6431 Fannin, MSB 4.126, Houston, TX 77030, USA
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28
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Abstract
Diffuse alveolar hemorrhage (DAH), a serious and frequently life-threatening process, can occur in a wide variety of disorders, including mitral stenosis, systemic autoimmune diseases, conditions associated with anti-neutrophil cytoplasmic antibodies, anti-glomerular basement membrane antibody, inhaled toxins or infection, and drug allergies. These causes have no common denominator, but the end result, of capillary inflammation and hemorrhage, is the same. The capillaritis seen in DAH is present exclusively in the lung and is not part of a more generalized systemic vasculitis. In a recent article, I highlighted the central role of the neutrophils in this process, and suggested that in DAH the neutrophils present in the lung may sift the associated immune complexes and transfer them out of the vascular system into the alveoli. In this article, we document the inflammation seen during the remission period and during the acute lung bleeding of DAH in 2 patients. Because DAH is a common finding in a variety of pathological conditions, we then explore the possible evolutionary mechanisms behind DAH.
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Affiliation(s)
- Schlomo Cohen
- Centre for Immunology and Allergy, Brussels, Belgium.
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Bazari H, Mauiyyedi S. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 4-2002. A 75-year-old man with acute renal failure five months after cystoprostatectomy and urethrectomy for carcinoma. N Engl J Med 2002; 346:353-60. [PMID: 11821513 DOI: 10.1056/nejmcpc020004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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30
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Abstract
Diffuse alveolar hemorrhage (DAH) is a rare yet serious and frequently life-threatening complication of a variety of conditions. DAH may result from coagulation disorders, inhaled toxins, or infections. Most cases of DAH are caused by capillaritis associated with systemic autoimmune diseases such as antineutrophil cytoplasmic antibodies-associated vasculitis, anti-glomerular basement membrane disease, and systemic lupus erythematosus. Early recognition is crucial, because the prompt institution of supportive measures and immunosuppressive therapy is required for survival. Our understanding of DAH and its management is largely empiric and based on small case series and individual reports, many dating back more than one decade. To provide the practicing specialist with a rational diagnostic and management approach to the patient with DAH, this review summarizes the most recent publications and salient information derived from older publications.
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Affiliation(s)
- U Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Abstract
Vasculitis, inflammation, and necrosis of blood vessels can involve any size or type of vessel in the pulmonary vasculature, including the capillaries, so-called capillaritis. Although pulmonary capillaritis is a histopathologic diagnosis that is not pathognomonic of a specific disorder, it usually signals the presence of an underlying systemic vasculitis or collagen vascular disease. Patients with pulmonary capillaritis usually present with bilateral infiltrates on chest radiographs and can be acutely ill with diffuse alveolar hemorrhage that may be life threatening. Therapy depends on diagnosis of the underlying disease that gave rise to the capillaritis. Since many of the disorders leading to capillaritis are treated by immunosuppression with corticosteroids and cyclophosphamide or azathioprine, infection must be excluded early in the course of therapy.
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Affiliation(s)
- T J Franks
- Department of Pulmonary and Mediastinal Pathology, Armed Forces Institute of Pathology, Washington, DC 20306-6000, USA.
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Abstract
Given the variability in rate of radiographic resolution, it remains controversial to decide when to initiate an invasive diagnostic work-up for nonresolving or slowly resolving pulmonary infiltrates. In immunocompetent patients who present with classical features of CAP (i.e., fever, chills, productive cough, new pulmonary infiltrate), clinical response to therapy is the most important determinant for further diagnostic studies. Within the first few days, persistence or even progression of infiltrates on chest radiographs is not unusual. Defervescence, diminished symptoms, and resolution of leukocytosis strongly support a response to antibiotic therapy, even when chest radiographic abnormalities persist. In this context, observation alone is reasonable, and invasive procedures can be deferred. Serial radiographs and clinical examinations dictate subsequent evaluation. In contrast, when clinical improvement has not occurred and chest radiographs are unchanged or worse, a more aggressive approach is warranted. In this setting, we advise fiberoptic bronchoscopy with BAL and appropriate cultures for bacteria, legionella, fungi, and mycobacteria. When endobronchial anatomy is normal and there is no purulence to suggest infection, TBBs should be done to exclude noninfectious causes (discussed earlier) or infections attributable to mycobacteria or fungi. An aggressive approach is also warranted in patients who are clinically stable or improving when the rate of radiographic resolution is delayed. As discussed earlier, what constitutes excessive delay is controversial, and depends upon the acuity of illness, specific pathogen, extent of involvement (i.e., lobar versus multilobar), comorbidities, and diverse host factors. Stable infiltrates even 2 to 4 weeks after institution of antibiotic therapy does not mandate intervention provided patients are improving clinically. Invasive techniques can also be deferred when unequivocal, albeit incomplete, radiographic resolution can be demonstrated. Lack of at least partial radiographic resolution by 6 weeks, even in asymptomatic patients, however, deserves consideration of alternative causes (e.g., endobronchial obstructing lesions, or noninfectious causes). Fiberoptic bronchoscopy with BAL and TBBs has minimal morbidity and is the preferred initial invasive procedure for detecting endobronchial lesions or substantiating noninfectious causes. The yield of bronchoscopy depends on demographics, radiographic features, and pre-test likelihood. In the absence of specific risk factors, the incidence of obstructing lesions (e.g., bronchogenic carcinomas, bronchial adenomas, obstructive foreign body) is low. Bronchogenic carcinoma is rare in nonsmoking, young (< 50 years) patients but is a legitimate consideration in older patients with a history of tobacco abuse. Non-neoplastic causes (e.g., pulmonary vasculitis, hypersensitivity pneumonia, etc.) should be considered when specific features are present (e.g., hematuria, appropriate epidemiologic exposures). Ancillary serologic tests or biopsies of extrapulmonary sites are invaluable in some cases. In rare instances, surgical (open or VATS) biopsy is necessary to diagnose refractory or non-resolving "pneumonias."
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Affiliation(s)
- T Kuru
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, USA
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33
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Abstract
The well-recognized pathology of the collagen vascular diseases is reviewed along with pathologic findings in systemic vasculitides that commonly involve the lung. The pathology of alveolar hemorrhage syndromes is also reviewed.
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Affiliation(s)
- T V Colby
- Mayo Clinic Scottsdale, Arizona, USA
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García-Rostan y Pérez GM, García Bragado F, Puras Gil AM. Pulmonary hemorrhage and antiglomerular basement membrane antibody-mediated glomerulonephritis after exposure to smoked cocaine (crack): a case report and review of the literature. Pathol Int 1997; 47:692-7. [PMID: 9361103 DOI: 10.1111/j.1440-1827.1997.tb04443.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A case of Goodpasture's syndrome with a negative immunofluorescence examination of the lung biopsy in a 32-year-old man is described. The patient was a 40 cigarettes per day smoker, who had been smoking cocaine (crack) up to 3 weeks before hospital admission. He developed a diffuse alveolar hemorrhage with extremely acute respiratory distress, followed by renal failure with anuria. Transjugular renal biopsy, immunofluorescence and serum antiglomerular basement membrane antibody titer studies confirmed the diagnosis of Goodpasture's syndrome without linear immunoglobulin G deposits as determined by immunofluorescence examination of the alveolar basement membranes. The case illustrates the potentially complex interrelations between an autoimmune disease and exposure to substances with possible antigenic properties, besides the imperative necessity for an early, accurate diagnosis and treatment for the potential for threatening life. Moreover, the association of Goodpasture's syndrome with crack has not been previously reported.
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Affiliation(s)
- G M García-Rostan y Pérez
- Department of Pathology, Hospital Virgen del Camino, Osasunbidea-Servicio Navarro de Salud, Pamplona, Spain
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35
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Abstract
Alveolar hemorrhage is an uncommon event that is associated with several underlying disorders, many of which are immunologically mediated. Careful evaluation of basic laboratory tests, extrapulmonary physical findings, and serology usually leads to the correct diagnosis. Significant overlap, however, exists, and pathologic (especially immunopathologic) evaluation of pulmonary or renal biopsies may be necessary. An accurate diagnosis is essential because treatment is most helpful when directed at the underlying diagnosis. Supportive therapy may be needed until the underlying disease is diagnosed and specific therapy is initiated.
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Affiliation(s)
- R A Dweik
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Ohio, USA
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36
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Green RJ, Ruoss SJ, Kraft SA, Duncan SR, Berry GJ, Raffin TA. Pulmonary capillaritis and alveolar hemorrhage. Update on diagnosis and management. Chest 1996; 110:1305-16. [PMID: 8915239 DOI: 10.1378/chest.110.5.1305] [Citation(s) in RCA: 167] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Pulmonary vascular inflammatory disorders may involve all components of the pulmonary vasculature, including capillaries. The principal histopathologic features of pulmonary capillaritis include capillary wall necrosis with infiltration by neutrophils, interstitial erythrocytes, and/or hemosiderin, and interalveolar septal capillary occlusion by fibrin thrombi. Immune complex deposition is variably present. Patients often present clinically with diffuse alveolar hemorrhage, which is characterized by dyspnea and hemoptysis; diffuse, bilateral, alveolar infiltrates on chest radiograph; and anemia. Pulmonary capillaritis has been reported with variable frequency and severity as a manifestation of Wegener's granulomatosis, microscopic polyarteritis, systemic lupus erythematosus, Goodpasture's syndrome, idiopathic pulmonary renal syndrome, Behçet's syndrome, Henoch-Schönlein purpura, IgA nephropathy, antiphospholipid syndrome, progressive systemic sclerosis, and diphenylhydantoin use. In addition to history, physical examination, and routine laboratory studies, certain ancillary laboratory tests, such as antineutrophil cytoplasmic antibodies, antinuclear antibodies, and antiglomerular basement membrane antibodies, may help diagnose an underlying disease. Diagnosis of pulmonary capillaritis can be made by fiberoptic bronchoscopy with transbronchial biopsy, but thoracoscopic biopsy is often employed. Since many disorders can result in pulmonary capillaritis with diffuse alveolar hemorrhage, it is crucial for clinicians and pathologists to work together when attempting to identify an underlying disease. Therapy depends on the disorder that gave rise to the pulmonary capillaritis and usually includes corticosteroids and cyclophosphamide or azathioprine. Since most diseases that result in pulmonary capillaritis are treated with immunosuppression, infection must be excluded aggressively.
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Affiliation(s)
- R J Green
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, CA 94305-5236, USA
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37
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McCarthy LJ, Cotton J, Danielson C, Graves V, Bergstein J. Goodpasture's syndrome in childhood: treatment with plasmapheresis and immunosuppression. J Clin Apher 1994; 9:116-9. [PMID: 7798157 DOI: 10.1002/jca.2920090204] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Goodpasture's syndrome rarely affects children. Therefore, we present our experience in a young boy whose pulmonary hemorrhage was dramatically resolved by three plasma exchanges. We believe the hemorrhage was caused primarily by acute capillaritis. He received cytoxan and steroids and a series of plasma exchanges which removed/suppressed his anti-glomerular basement membrane (anti-GBM) antibody production. However, after a year, his renal function did not return, and he required renal transplantation and continues to do well.
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Affiliation(s)
- L J McCarthy
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis 46202-5283
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38
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Harrity P, Gilbert-Barness E, Cabalka A, Hong R, Zimmerman J. Isolated pulmonary Goodpasture syndrome. PEDIATRIC PATHOLOGY 1991; 11:635-46. [PMID: 1946080 DOI: 10.3109/15513819109064795] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The case of a 13-year-old girl with Goodpasture syndrome is reported. The presentation at this age with only pulmonary hemorrhage is unusual among Goodpasture syndrome patients. The case illustrates well the diagnostic difficulties in Goodpasture syndrome. The choices of treatment modalities available for this disease and the results and risks of such treatment options are reviewed. A discussion and classification of diffuse pulmonary hemorrhage is presented. The case emphasizes that Goodpasture syndrome should be considered in the differential diagnosis of diffuse pulmonary hemorrhage in spite of a lack of renal abnormalities and that serum anti-glomerular basement membrane antibody testing can be of great help in confirming the diagnosis.
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Affiliation(s)
- P Harrity
- Department of Pathology, University of Wisconsin Hospital and Clinics, Madison 53792
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