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Cheffai A, Kechida M. Autoimmune diseases and myelodysplastic syndromes. Reumatologia 2024; 62:52-57. [PMID: 38558894 PMCID: PMC10979376 DOI: 10.5114/reum/184157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 02/16/2024] [Indexed: 04/04/2024] Open
Abstract
Autoimmune diseases (ADs) and myelodysplastic syndrome (MDS) may be associated in approximately 10-20% of cases. Although this association has been well recognized, it is not always easily diagnosed. The exact physiopathological mechanism involved has yet to be determined but seems to be multifactorial. The therapeutic decision is not well codified and often represents a challenge. But overall, glucocorticosteroids have generally proven to be effective at the expense of a high incidence of dependence and relapse. This review aims to summarize and analyze all aspects of this association to provide an overview for practitioners and clinicians. A scientific search in databases (PubMed, Scopus, Web of Science, Google Scholar) was conducted using a combination of key words such as autoimmune diseases, myelodysplastic syndromes, and association. Articles from 1992 to 2022 were considered and relevant data were collected and summarized to provide a coherent detailed overview of the coexistence of ADs and MDS.
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Affiliation(s)
- Arij Cheffai
- Department of Internal Medicine and Endocrinology, Fattouma Bourguiba University Hospital, University of Monastir, Tunisia
| | - Melek Kechida
- Department of Internal Medicine and Endocrinology, Fattouma Bourguiba University Hospital, University of Monastir, Tunisia
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2
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Odler B, Windpessl M, Eller K, Säemann MD, Lhotta K, Neumann I, Öberseder G, Duftner C, Dejaco C, Rudnicki M, Gauckler P, Hintenberger R, Zwerina J, Thiel J, Kronbichler A. [Diagnosis and therapy of granulomatosis with polyangiitis and microscopic polyangiitis-2023: consensus of the Austrian society of nephrology (ÖGN) and Austrian society of rheumatology (ÖGR)]. Wien Klin Wochenschr 2023; 135:656-674. [PMID: 37728651 PMCID: PMC10511611 DOI: 10.1007/s00508-023-02262-9] [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] [Accepted: 07/24/2023] [Indexed: 09/21/2023]
Abstract
ANCA-associated vasculitides (AAV) are rare, complex systemic diseases that are often difficult to diagnose, because of unspecific clinical symptoms at presentation. However, the clinical course may be very dramatic and even life-threatening, necessitating prompt diagnosis and treatment.Therefore, it is important to increase disease awareness among physicians and support colleagues who are not confronted with these rare diseases on a regular basis. Here, the Austrian Society of Nephrology (ÖGN) and the Austrian Society of Rheumatology (ÖGR) provide a joint consensus on how to best diagnose and manage patients with granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA).
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Affiliation(s)
- Balazs Odler
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Martin Windpessl
- Abteilung für Innere Medizin IV, Klinikum Wels-Grieskirchen, Wels, Österreich
- Medizinische Fakultät, JKU, Linz, Österreich
| | - Kathrin Eller
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Marcus D Säemann
- 6. Medizinische Abteilung mit Nephrologie & Dialyse, Klinik Ottakring, Wien, Österreich
- Medizinische Fakultät, SFU, Wien, Österreich
| | - Karl Lhotta
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Irmgard Neumann
- Vasculitis.at, Wien, Österreich
- Immunologiezentrum Zürich (IZZ), Zürich, Schweiz
| | | | - Christina Duftner
- Department Innere Medizin II, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | | | - Michael Rudnicki
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Philipp Gauckler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Rainer Hintenberger
- Abteilung Innere Medizin 2 (Gastroenterologie und Hepatologie, Endokrinologie und Stoffwechsel, Nephrologie, Rheumatologie), JKU, Linz, Österreich
| | - Jochen Zwerina
- 1. Medizinische Abteilung, Hanusch Krankenhaus, Wien, Österreich
| | - Jens Thiel
- Klinische Abteilung für Rheumatologie und Immunologie, Bereich Innere Medizin, Medizinische Universität Graz, Graz, Österreich
| | - Andreas Kronbichler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich.
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Samson M, Devilliers H, Thietart S, Charles P, Pagnoux C, Cohen P, Karras A, Mouthon L, Terrier B, Puéchal X, Guillevin L. Score to assess the probability of relapse in granulomatosis with polyangiitis and microscopic polyangiitis. RMD Open 2023; 9:rmdopen-2022-002953. [PMID: 36972927 PMCID: PMC10069598 DOI: 10.1136/rmdopen-2022-002953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/12/2023] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVE To develop a score assessing the probability of relapse in granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). METHODS Long-term follow-up data from GPA and MPA patients included in five consecutive randomised controlled trials were pooled. Patient characteristics at diagnosis were entered into a competing-risks model, with relapse as the event of interest and death the competing event. Univariate and multivariate analyses were computed to identify variables associated with relapse and build a score, which was then validated in an independent cohort of GPA or MPA patients. RESULTS Data collected from 427 patients (203 GPA, 224 MPA) at diagnosis were included. Mean±SD follow-up was 80.6±51.3 months; 207 (48.5%) patients experienced ≥1 relapse. Relapse risk was associated with proteinase 3 (PR3) positivity (HR=1.81 (95% CI 1.28 to 2.57); p<0.001), age ≤75 years (HR=1.89 (95% CI 1.15 to 3.13); p=0.012) and estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m² (HR=1.67 (95% CI 1.18 to 2.33); p=0.004) at diagnosis. A score, the French Vasculitis Study Group Relapse Score (FRS), from 0 to 3 points was modelised: 1 point each for PR3-antineutrophil cytoplasmic antibody positivity, eGFR ≥30 mL/min/1.73 m² and age ≤75 years. In the validation cohort of 209 patients, the 5-year relapse risk was 8% for a FRS of 0, 30% for 1, 48% for 2 and 76% for 3. CONCLUSION The FRS can be used at diagnosis to assess the relapse risk in patients with GPA or MPA. Its value for tailoring the duration of maintenance therapy should be evaluated in future prospective trials.
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Affiliation(s)
- Maxime Samson
- Department of Internal Medicine and Clinical Immunology, University Hospital Centre Dijon Bourgogne, Dijon, France
| | - Hervé Devilliers
- INSERM, CIC 1432, Clinical Epidemiology Unit, University of Burgundy, Dijon, France
| | - Sara Thietart
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Pitié Salpêtrière, Paris, France
| | - Pierre Charles
- Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Pascal Cohen
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Alexandre Karras
- Department of Nephrology, AP-HP, Hopital Europeen Georges Pompidou, Paris, France
- Universite Paris Descartes, Paris, France
| | - Luc Mouthon
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Xavier Puéchal
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Loic Guillevin
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Paris, France
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Xu L, Song X, Dai Q, Lin N, Hong S. Images in Vascular Medicine: Rapid limb deterioration due to polyarteritis nodosa. Vasc Med 2022; 27:604-605. [PMID: 36190788 DOI: 10.1177/1358863x221124679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Liping Xu
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xinwei Song
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qiaoding Dai
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Na Lin
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Shouhai Hong
- Acupuncture Department, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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Alba MA, Jennette JC, Hu Y, Poulton CJ, Blazek L, Derebail VK, Falk RJ, Hogan SL. Relevance of Combined Clinicopathologic Phenotype and Antineutrophil Cytoplasmic Autoantibody Serotype in the Diagnosis of Antineutrophil Cytoplasmic Autoantibody Vasculitis. Kidney Int Rep 2022; 7:2676-2690. [PMID: 36506241 PMCID: PMC9727534 DOI: 10.1016/j.ekir.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), 2 major clinicopathologic variants of antineutrophil cytoplasmic autoantibody (ANCA) vasculitides, are mostly associated with proteinase 3 (PR3)-ANCA and myeloperoxidase (MPO)-ANCA, respectively. Less is known regarding the uncommon forms of ANCA vasculitis, PR3-ANCA MPA and MPO-ANCA GPA. Methods In this cohort study we detailed the clinical presentation and outcome of patients with PR3-ANCA MPA and MPO-ANCA GPA from the Glomerular Disease Collaborative Network (GDCN) inception cohort. Baseline clinical manifestations, relapses, end-stage kidney disease (ESKD), and survival were compared within MPA cases by PR3-ANCA (n = 116) versus MPO-ANCA (n = 173) and within GPA cases by PR3-ANCA (n = 108) versus MPO-ANCA (n = 43). Fisher's exact test and Wilcoxon two sample test were used for comparisons. Proportional hazards models were used to evaluate the development of relapses, ESKD, and death. Results Patients with PR3-ANCA MPA were younger (53 years vs. 62 years, P = 0.0007) and had increased prevalence of joint involvement (56% vs. 40%, P = 0.0115) and ear, nose, and throat (ENT) involvement (44% vs. 26%, P = 0.002) than MPO-ANCA MPA. Relapses, ESKD, and survival were similar between both MPA subsets. Within the GPA group, patients with MPO-ANCA GPA were older (61 years vs. 46 years, P = 0.0007) and more likely female (56% vs. 35%, P = 0.027) than PR3-ANCA GPA patients. MPO-ANCA GPA was also characterized by less prevalent ENT manifestations (58% vs. 77%, P = 0.028) and neurologic manifestations (5% vs. 25%, P = 0.0029), and increased ESKD and mortality. Conclusions PR3-ANCA MPA and MPO-ANCA GPA are clinicopathologically distinct subsets of ANCA vasculitis that differ from MPO-ANCA MPA and PR3-ANCA GPA. Although the impact of these differences on the clinical management and outcome warrants further evaluation, these results support the recommendation of including both the phenotypic diagnosis and ANCA serotype in the diagnosis of ANCA vasculitis.
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Affiliation(s)
- Marco A. Alba
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yichun Hu
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Caroline J. Poulton
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lauren Blazek
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Vimal K. Derebail
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ronald J. Falk
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan L. Hogan
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Puéchal X, Guillevin L. How best to manage relapse and remission in ANCA-associated vasculitis. Expert Rev Clin Immunol 2022; 18:1135-1143. [PMID: 36102147 DOI: 10.1080/1744666x.2022.2122954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION A 2-stage therapeutic approach is now applied as standard-of-care to treat ANCA-associated vasculitides (AAVs): first, glucocorticoids (GCs) combined with cyclophosphamide (CYC) or rituximab (RTX) to induce remission, then relapse prevention with remission-maintenance therapy. Nonetheless, a substantial risk of relapse persists. AREAS COVERED The authors provide an overview of the current state of maintenance therapies, and discuss new strategies recommended to prevent and treat relapses, focusing on granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). EXPERT OPINION For remission-induction after GPA or MPA relapse with organ-threatening manifestations, reintroduction or intensification of the GC dose in combination with CYC or RTX cycle is recommended; we prefer RTX in light of its superior responses obtained in patients with relapsing disease. Rapid tapering of GCs has been shown not to alter AAV evolution while decreasing the risk of serious infections. In contrast, for non-severe, active MPA, we recommend GCs alone as first-line therapy. For patients whose MPA remains uncontrolled by GCs alone, immunosuppressant adjunction can be a GC-sparing option or to counter GC intolerance. Once remission is achieved, we recommend prolonged maintenance therapy with preemptive low-dose (500 mg) RTX infusion biannually.
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Affiliation(s)
- Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP).Centre, Université Paris Cité, Paris, France.,French Vasculitis Study Group, Hôpital Cochin, Paris, France
| | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP).Centre, Université Paris Cité, Paris, France.,French Vasculitis Study Group, Hôpital Cochin, Paris, France
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7
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Box CD, Cronin O, Hauser B. The Impact of High Dose Glucocorticoids on Bone Health and Fracture Risk in Systemic Vasculitides. Front Endocrinol (Lausanne) 2022; 13:806361. [PMID: 35250864 PMCID: PMC8889574 DOI: 10.3389/fendo.2022.806361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/07/2022] [Indexed: 12/29/2022] Open
Abstract
Systemic vasculitides are a range of conditions characterized by inflammation of blood vessels which may manifest as single organ or life-threatening multisystem disease. The treatment of systemic vasculitis varies depending on the specific disease but historically has involved initial treatment with high dose glucocorticoids alone or in conjunction with other immunosuppressive agents. Prolonged glucocorticoid treatment is frequently required as maintenance treatment. Patients with small and large vessel vasculitis are at increased risk of fracture. Osteoporosis may occur due to intrinsic factors such as chronic inflammation, impaired renal function and to a large extent due to pharmacological therapy with high dose glucocorticoid or combination treatments. This review will outline the known mechanism of bone loss in vasculitis and will summarize factors attributing to fracture risk in different types of vasculitis. Osteoporosis treatment with specific consideration for patients with vasculitis will be discussed. The use of glucocorticoid sparing immunosuppressive agents in the treatment of systemic vasculitis is a significant area of ongoing research. Adjunctive treatments are used to reduce cumulative doses of glucocorticoids and therefore may significantly decrease the associated fracture risk in patients with vasculitis. Lastly, we will highlight the many unknowns in the relation between systemic vasculitis, its treatment and bone health and will outline key research priorities for this field.
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Affiliation(s)
| | - Owen Cronin
- Department of Rheumatology, Bon Secours Hospital Cork, Cork, Ireland
- School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Barbara Hauser
- Rheumatic Disease Unit, Western General Hospital, Edinburgh, United Kingdom
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
- *Correspondence: Barbara Hauser,
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White M, Reginato AM, Cunha JS. Evolving Chest Pain in a Young Male. Arthritis Care Res (Hoboken) 2021; 74:867-878. [PMID: 34619016 DOI: 10.1002/acr.24802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 09/21/2021] [Accepted: 09/21/2021] [Indexed: 11/10/2022]
Abstract
A 33-year-old Hispanic male with a history of recent orchiectomy for suspected testicular cancer presented to the emergency department with worsening exertional chest pain and dyspnea in the setting of a 2-month history of diffuse myalgias and symmetric polyarthralgias.
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Affiliation(s)
- Matthew White
- Division of Rheumatology. Lifespan Physician Group, Pawtucket
| | - Anthony M Reginato
- Division of Rheumatology. The Warren Alpert Medical School of Brown University
| | - Joanne S Cunha
- Division of Rheumatology. The Warren Alpert Medical School of Brown University
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Arbaoui S, Al Tayef TA, Miry A, Rezziki A, Benzirar A, El Mahi O. [A periarteritisnodosa presenting as bilateral sub-acute limb ischemia of the legs]. Ann Cardiol Angeiol (Paris) 2021; 70:253-255. [PMID: 34517973 DOI: 10.1016/j.ancard.2021.07.005] [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: 01/07/2021] [Accepted: 07/01/2021] [Indexed: 11/17/2022]
Abstract
STUDY'S GOAL As there are no guidelines. This short report shows our experience in management of sub-acute limb ischemia with polyarteritisnodosa. INTRODUCTION Acute limb ischemia is rarely seen in periarteritisnodosa. CASE REPORT Here, we present a case with peripheral vascular disease of both lower limbs leading to foot claudication and then a subacute limb ischemia with large necrotic plaques on the lower limb. Angioscan showed occlusion of both superficial femoral arteries. Angiographic imaging showed abnormalities in medium-sized arteries. Pathological study of biopsy from the artery, vein, nerve and skin of the amputated leg confirm the diagnosis of periarteritisnodosa. She benefited from femoral popliteal bypass in both legs, anticoagulant drug and steroids. The non-amelioration of the left leg led to his amputation. The right leg was healed.
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Affiliation(s)
- S Arbaoui
- Département de ChirurgieVasculaire, Université Mohammed Premier, Centre HospitalierUniversitaire Mohammed VI, Oujda.
| | - T Abu Al Tayef
- Département de ChirurgieVasculaire, Université Mohammed Premier, Centre HospitalierUniversitaire Mohammed VI, Oujda
| | - A Miry
- Départementd'Anatomopathologie, Université Mohammed Premier, Centre HospitalierUniversitaire Mohammed VI, Oujda
| | - A Rezziki
- Département de ChirurgieVasculaire, Université Mohammed Premier, Centre HospitalierUniversitaire Mohammed VI, Oujda
| | - A Benzirar
- Département de ChirurgieVasculaire, Université Mohammed Premier, Centre HospitalierUniversitaire Mohammed VI, Oujda
| | - O El Mahi
- Département de ChirurgieVasculaire, Université Mohammed Premier, Centre HospitalierUniversitaire Mohammed VI, Oujda
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10
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Chung SA, Gorelik M, Langford CA, Maz M, Abril A, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot M, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Polyarteritis Nodosa. Arthritis Rheumatol 2021; 73:1384-1393. [PMID: 34235883 DOI: 10.1002/art.41776] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/13/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of systemic polyarteritis nodosa (PAN). METHODS Twenty-one clinical questions regarding diagnostic testing, treatment, and management were developed in the population, intervention, comparator, and outcome (PICO) format for systemic, non-hepatitis B-related PAN. Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence and formulate recommendations. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 16 recommendations and 1 ungraded position statement for PAN. Most recommendations were graded as conditional due to the paucity of evidence. These recommendations support early treatment of severe PAN with cyclophosphamide and glucocorticoids, limiting toxicity through minimizing long-term exposure to both treatments, and the use of imaging and tissue biopsy for disease diagnosis. These recommendations endorse minimizing risk to the patient by using established therapy at disease onset and identify new areas where adjunctive therapy may be warranted. CONCLUSION These recommendations provide guidance regarding diagnostic strategies, use of pharmacologic agents, and imaging for patients with PAN.
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Affiliation(s)
| | | | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
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11
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Chung SA, Gorelik M, Langford CA, Maz M, Abril A, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot M, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Polyarteritis Nodosa. Arthritis Care Res (Hoboken) 2021; 73:1061-1070. [PMID: 34235889 DOI: 10.1002/acr.24633] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/13/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of systemic polyarteritis nodosa (PAN). METHODS Twenty-one clinical questions regarding diagnostic testing, treatment, and management were developed in the population, intervention, comparator, and outcome (PICO) format for systemic, non-hepatitis B-related PAN. Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence and formulate recommendations. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 16 recommendations and 1 ungraded position statement for PAN. Most recommendations were graded as conditional due to the paucity of evidence. These recommendations support early treatment of severe PAN with cyclophosphamide and glucocorticoids, limiting toxicity through minimizing long-term exposure to both treatments, and the use of imaging and tissue biopsy for disease diagnosis. These recommendations endorse minimizing risk to the patient by using established therapy at disease onset and identify new areas where adjunctive therapy may be warranted. CONCLUSION These recommendations provide guidance regarding diagnostic strategies, use of pharmacologic agents, and imaging for patients with PAN.
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Affiliation(s)
| | | | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
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12
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Conticini E, Sota J, Falsetti P, Lamberti A, Miracco C, Guarnieri A, Frediani B, Cantarini L. Biologic drugs in the treatment of polyarteritis nodosa and deficit of adenosine deaminase 2: A narrative review. Autoimmun Rev 2021; 20:102784. [PMID: 33609794 DOI: 10.1016/j.autrev.2021.102784] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/03/2021] [Indexed: 11/17/2022]
Abstract
Polyarteritis nodosa (PAN) is a medium vessels vasculitis variously involving different organs and systems, sometimes with an aggressive course, leading to death or disability in a significant number of cases. First-line treatment usually relies on steroids and classical immunosuppressants, but a growing number of case reports and small case series shows the potential role of biologic drugs, mostly anti-tumor necrosis factor (TNF)-α agents, in inducing and maintaining remission in patients affected by PAN. Similarly, the recently described autoinflammatory disease named deficit of adenosine deaminase 2 (DADA2), considered by several experts as a more precocious and aggressive variant of PAN, seems to respond to a prompt treatment with TNF-α inhibitors. The aim of this review is to collect all existing evidences about the use of biologic drugs in PAN and DADA2. Fifty-one articles published during the last 15 years were retrieved, including 58 and 76 patients affected by PAN and DADA2, respectively, and treated with biologic drugs. The majority of subjects was treated with TNF-α inhibitors, whose effectiveness was reported in the treatment of such difficult-to-manage diseases, particularly in DADA2. Among the other biologic drugs, Tocilizumab was successfully employed in some subjects affected by PAN who did not respond to TNF-α inhibitors, while Rituximab did not give substantial benefits neither in PAN nor in DADA2. Only few data exist about the role of Janus-kinase inhibitors and anti-IL1 agents. This study provides the first comprehensive assessment of biologic agents in both PAN and DADA2, with encouraging results especially in the context of TNF-α inhibitors. Nevertheless, due to the lack of prospective, randomized, case control studies, further efforts should be made in order to fully elucidate the role of these drugs in such rare and life-threatening conditions.
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Affiliation(s)
- Edoardo Conticini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Jurgen Sota
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Paolo Falsetti
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Arianna Lamberti
- Dermatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Clelia Miracco
- Pathological Anatomy Unit, Department of Medical, Surgical and Neurological Science, University of Siena, Siena, Italy
| | - Andrea Guarnieri
- Nephrology, Dialysis and Transplantation Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Bruno Frediani
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Luca Cantarini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Italy.
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Callen A, Narvid J, Chen X, Gregath T, Meisel K. Neurovascular disease, diagnosis, and therapy: Cervical and intracranial atherosclerosis, vasculitis, and vasculopathy. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:249-266. [PMID: 33272399 DOI: 10.1016/b978-0-444-64034-5.00023-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Stroke is a leading cause of death, disability, and financial burden in the United States. Perhaps more than any other disease process, the rapidity with which the diagnosis and treatment of stroke are successfully achieved is paramount to the reduction of its associated morbidity and mortality. Steno-occlusive intracranial vascular disease, the most notorious culprit of cerebral ischemia and/or hemorrhage, traces its etiology to native and embolic atherosclerosis as well as various forms of vascular inflammation, insult, and dysfunction. Distinguishing between these causes is a critical first step in the diagnosis and treatment of a patient presenting with cerebrovascular compromise. In this chapter, we delineate the clinical and imaging features of cervical and intracranial atherosclerosis, vasculitis, and vasculopathy, along with the evidence behind the treatments which comprise their current-day standard of care. The modern imaging armamentarium is diverse and complex, with contrast-enhanced and non-contrast MR angiography, CT angiography, digital subtraction angiography, and ultrasound; each playing an important role in providing rapid insight into the patient's disease process. Understanding these imaging techniques and their application in the acute setting is critical for the provider caring for stroke patients.
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Affiliation(s)
- Andrew Callen
- Department of Radiology, University of Colorado, Boulder, CO, United States
| | - Jared Narvid
- Department of Radiology, University of California San Francisco, San Francisco, CA, United States
| | - Xiaolin Chen
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Trevor Gregath
- Department of Neurology, Bryan Health, Lincoln, NE, United States
| | - Karl Meisel
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States.
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Terrier B, Darbon R, Durel CA, Hachulla E, Karras A, Maillard H, Papo T, Puechal X, Pugnet G, Quemeneur T, Samson M, Taille C, Guillevin L. French recommendations for the management of systemic necrotizing vasculitides (polyarteritis nodosa and ANCA-associated vasculitides). Orphanet J Rare Dis 2020; 15:351. [PMID: 33372616 PMCID: PMC7771069 DOI: 10.1186/s13023-020-01621-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Systemic necrotizing vasculitis comprises a group of diseases resembling polyarteritis nodosa and anti-neutrophil cytoplasmic antibody-associated vasculitis (ANCA): granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, and microscopic polyangiitis. The definitive diagnosis is made in cooperation with a reference center for autoimmune diseases and rare systemic diseases or a competency center. The management goals are: to obtain remission and, in the long term, healing; to reduce the risk of relapses; to limit and reduce the sequelae linked to the disease; to limit the side effects and the sequelae linked to the treatments; to improve or at least maintain the best possible quality of life; and to maintain socio-professional integration and/or allow a rapid return to school and/or professional activity. Information and therapeutic education of the patients and those around them are an integral part of the care. All health professionals and patients should be informed of the existence of patient associations. The treatment of vasculitis is based on variable combinations of glucocorticoids and immunosuppressants, chosen and adapted according to the disease concerned, the severity and/or extent of the disease, and the underlying factors (age, kidney function, etc.). Follow-up clinical and paraclinical examinations must be carried out regularly to clarify the progression of the disease, detect and manage treatment failures and possible relapses early on, and limit sequelae and complications (early then late) related to the disease or treatment. A distinction is made between the induction therapy, lasting approximately 3–6 months and aimed at putting the disease into remission, and the maintenance treatment, lasting 12–48 months, or even longer. The role of the increase or testing positive again for ANCA as a predictor of a relapse, which has long been controversial, now seems to have greater consensus: Anti-myeloperoxidase ANCAs are less often associated with a relapse of vasculitis than anti-PR3 ANCA.
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Affiliation(s)
| | | | | | | | | | | | - Thomas Papo
- Internal Medicine, CHU Bichat, AP-HP, Paris, France
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Bala MM, Malecka-Massalska TJ, Koperny M, Zajac JF, Jarczewski JD, Szczeklik W. Anti-cytokine targeted therapies for ANCA-associated vasculitis. Cochrane Database Syst Rev 2020; 9:CD008333. [PMID: 32990324 PMCID: PMC8094990 DOI: 10.1002/14651858.cd008333.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Anti-neutrophilic cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) are a group of rare auto-inflammatory diseases that affects mainly small vessels. AAV includes: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA). Anti-cytokine targeted therapy uses biological agents capable of specifically targeting and neutralising cytokine mediators of the inflammatory response. OBJECTIVES To assess the benefits and harms of anti-cytokine targeted therapy for adults with AAV. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (2019, Issue 7), MEDLINE and Embase up to 16 August 2019. We also examined reference lists of articles, clinical trial registries, websites of regulatory agencies and contacted manufacturers. SELECTION CRITERIA Randomised controlled trials (RCTs) or controlled clinical trials of targeted anti-cytokine therapy in adults (18 years or older) with AAV compared with placebo, standard therapy or another modality and anti-cytokine therapy of different type or dose. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included four RCTs with a total of 440 participants (mean age 48 to 56 years). We analysed the studies in three groups: 1) mepolizumab (300 mg; three separate injections every four weeks for 52 weeks) versus placebo in participants with relapsing or refractory EGPA; 2) belimumab (10 mg/kg on days 0, 14, 28 and every 28 days thereafter until 12 months after the last participant was randomised) or etanercept (25 mg twice a week) with standard therapy (median 25 months) versus placebo with standard therapy (median 19 months) in participants with GPA/MPA; and 3) infliximab (3 mg/kg on days 1 and 14, before the response assessment on day 42) versus rituximab (0.375g/m2 on days 1, 8, 15 and 22) in participants with refractory GPA for up to 12 months. None of the studies were assessed as low risk of bias in all domains: one study did not report randomisation or blinding methods clearly. Three studies were at high risk and one study was at unclear risk of bias for selective outcome reporting. One trial with 136 participants with relapsing or refractory EGPA compared mepolizumab with placebo during 52 weeks of follow-up and observed one death in the mepolizumab group (1/68, 1.5%) and none in the placebo group (0/68, 0%) (Peto odds ratio (OR) 7.39, 95% confidence interval (CI) 0.15 to 372.38; low-certainty evidence). Low-certainty evidence suggests that more participants in the mepolizumab group had ≥ 24 weeks of accrued remission over 52 weeks compared to placebo (27.9% versus 2.9%; risk ratio (RR) 9.5, 95% CI 2.30 to 39.21), and durable remission within the first 24 weeks sustained until week 52 (19.1% mepolizumab versus 1.5% placebo; RR 13.0, 95% CI 1.75 to 96.63; number needed to treat for an additional beneficial outcome (NNTB) 6, 95% Cl 4 to 13). Mepolizumab probably decreases risk of relapse (55.8% versus 82.4%; RR 0.68, 95% CI 0.53 to 0.86; NNTB 4, 95% CI 3 to 9; moderate-certainty evidence). There was low-certainty evidence regarding similar frequency of adverse events (AEs): total AEs (96.9% versus 94.1%; RR 1.03, 95% CI 0.96 to 1.11), serious AEs (17.7% versus 26.5%; RR 0.67, 95% CI 0.35 to 1.28) and withdrawals due to AEs (2.9% versus 1.5%; RR 2.00, 95% CI 0.19 to 21.54). Disease flares were not measured. Based on two trials with different follow-up periods (mean of 27 months for etanercept study; up to four years for belimumab study) including people with GPA (n = 263) and a small group of participants with MPA (n = 22) analysed together, we found low-certainty evidence suggesting that adding an active drug (etanercept or belimumab) to standard therapy does not increase or reduce mortality (3.4% versus 1.4%; Peto OR 2.45, 95% CI 0.55 to 10.97). Etanercept may have little or no effect on remission (92.3% versus 89.5%; RR 0.97, 95% CI 0.89 to 1.07), durable remission (70% versus 75.3%; RR 0.93, 95% CI 0.77 to 1.11; low-certainty evidence) and disease flares (56% versus 57.1%; RR 0.98, 95% CI 0.76 to 1.27; moderate-certainty evidence). Low-certainty evidence suggests that belimumab does not increase or reduce major relapse (1.9% versus 0%; RR 2.94, 95% CI 0.12 to 70.67) or any AE (92.5% versus 82.7%; RR 1.12, 95% CI 0.97 to 1.29). Low-certainty evidence suggests a similar frequency of serious or severe AEs (47.6% versus 47.6%; RR 1.00, 95% CI 0.80 to 1.27), but more frequent withdrawals due to AEs in the active drug group (11.2%) compared to the placebo group (4.2%), RR 2.66, 95% CI 1.07 to 6.59). One trial involving 17 participants with refractory GPA compared infliximab versus rituximab added to steroids and cytotoxic agents for 12 months. One participant died in each group (Peto OR 0.88, 95% CI, 0.05 to 15.51; 11% versus 12.5%). We have very low-certainty evidence for remission (22% versus 50%, RR 0.44, 95% Cl 0.11 to 1.81) and durable remission (11% versus 50%, RR 0.22, 95% CI 0.03 to 1.60), any severe AE (22.3% versus 12.5%; RR 1.78, 95% CI 0.2 to 16.1) and withdrawals due to AEs (0% versus 0%; RR 2.70, 95% CI 0.13 to 58.24). Disease flare/relapse and the frequency of any AE were not reported. AUTHORS' CONCLUSIONS We found four studies but concerns about risk of bias and small sample sizes preclude firm conclusions. We found moderate-certainty evidence that in patients with relapsing or refractory EGPA, mepolizumab compared to placebo probably decreases disease relapse and low-certainty evidence that mepolizumab may increase the probability of accruing at least 24 weeks of disease remission. There were similar frequencies of total and serious AEs in both groups, but the study was too small to reliably assess these outcomes. Mepolizumab may result in little to no difference in mortality. However, there were very few events. In participants with GPA (and a small subgroup of participants with MPA), etanercept or belimumab may increase the probability of withdrawal due to AEs and may have little to no impact on serious AEs. Etanercept may have little or no impact on durable remission and probably does not reduce disease flare.
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Affiliation(s)
- Malgorzata M Bala
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Teresa J Malecka-Massalska
- Rheumatology Department, Provincial Hospital, Radzyn Podlaski, Lublin, Poland
- Physiology Department, Medical University of Lublin, Lublin, Poland
| | - Magdalena Koperny
- Systematic Reviews Unit, Jagiellonian University Medical College, Krakow, Poland
| | - Joanna F Zajac
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
- Systematic Reviews Unit, Jagiellonian University Medical College, Krakow, Poland
| | - Jarosław D Jarczewski
- Department of Pathophysiology, Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Szczeklik
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland
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Safe and successful treatment of refractory polyarteritis nodosa with tocilizumab in a patient with past hepatitis B virus infection: a case-based review. Clin Rheumatol 2020; 40:2065-2070. [PMID: 32833086 DOI: 10.1007/s10067-020-05345-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/04/2020] [Accepted: 08/11/2020] [Indexed: 12/13/2022]
Abstract
Polyarteritis nodosa is a primary systemic necrotizing vasculitis whose evolution follows, in many cases, a chronic remitting-recurrent course with refractoriness to conventional immunosuppressants. We report here the clinical case of a 75-year-old patient with serologies suggestive of past hepatitis B virus infection who presented a flare of polyarteritis nodosa with great secondary functional impairment. She had not responded to several previous immunosuppressants and required high doses of glucocorticoids to control the flare. After the initiation of biological therapy with tocilizumab, the patient experienced a rapid and marked clinical and analytical improvement, going into clinical remission and being able to remarkably lower the corticosteroid dose and stop the rest of the immunosuppressants. There was no evidence of hepatitis B virus reactivation or changes in the titers of any of the parameters related to the aforementioned infection. This clinical case represents the first case reported in the literature about the successful and safe treatment of polyarteritis nodosa with tocilizumab in a patient with serologies suggestive of past hepatitis B virus infection.
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17
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Guillevin L. Treatment of systemic necrotizing vasculitides: The 40-year experience of the French Vasculitis Study Group. Presse Med 2020; 49:104034. [PMID: 32650043 DOI: 10.1016/j.lpm.2020.104034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 05/19/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022] Open
Abstract
Treatment of vasculitides has benefited from the results of several prospective clinical trials focusing on the evaluation of new drugs, therapeutic strategies and adjuvant treatments. In the field of autoimmunity, vasculitides are the group of diseases for which the most important medical progress has been made, combining advances in understanding the pathogenetic mechanisms, classification of the various entities and willingness to evaluate treatments. Several international groups have been actively involved in these tasks. The French Vasculitis Study Group was the first to design and organize prospective trials in the field and to contribute to these medical advances. In this review, we analyze the different treatments and therapeutic strategies evaluated over the last few decades and, more precisely, the last 39 years by the French Vasculitis Study Group.
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Affiliation(s)
- Loïc Guillevin
- Department of Internal Medicine, Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, Paris, France.
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Isobe M, Amano K, Arimura Y, Ishizu A, Ito S, Kaname S, Kobayashi S, Komagata Y, Komuro I, Komori K, Takahashi K, Tanemoto K, Hasegawa H, Harigai M, Fujimoto S, Miyazaki T, Miyata T, Yamada H, Yoshida A, Wada T, Inoue Y, Uchida HA, Ota H, Okazaki T, Onimaru M, Kawakami T, Kinouchi R, Kurata A, Kosuge H, Sada KE, Shigematsu K, Suematsu E, Sueyoshi E, Sugihara T, Sugiyama H, Takeno M, Tamura N, Tsutsumino M, Dobashi H, Nakaoka Y, Nagasaka K, Maejima Y, Yoshifuji H, Watanabe Y, Ozaki S, Kimura T, Shigematsu H, Yamauchi-Takihara K, Murohara T, Momomura SI. JCS 2017 Guideline on Management of Vasculitis Syndrome - Digest Version. Circ J 2020; 84:299-359. [PMID: 31956163 DOI: 10.1253/circj.cj-19-0773] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University
| | - Yoshihiro Arimura
- Department of Rheumatology and Nephrology, Kyorin University School of Medicine.,Internal Medicine, Kichijoji Asahi Hospital
| | - Akihiro Ishizu
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University
| | - Shinya Kaname
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine
| | | | - Yoshinori Komagata
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Graduate School of Medicine
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Kei Takahashi
- Department of Pathology, Toho University Ohashi Medical Center
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
| | - Hitoshi Hasegawa
- Department of Hematology, Clinical Immunology, and Infectious Diseases, Ehime University Graduate School of Medicine
| | - Masayoshi Harigai
- Department of Rheumatology, School of Medicine, Tokyo Women's Medical University
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki
| | | | - Tetsuro Miyata
- Vascular Center, Sanno Hospital and Sanno Medical Center
| | - Hidehiro Yamada
- Medical Center for Rheumatic Diseases, Seirei Yokohama Hospital
| | | | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Graduate School of Medical Sciences, Kanazawa University
| | | | - Haruhito A Uchida
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hideki Ota
- Department of Advanced MRI Collaboration Research, Tohoku University Graduate School of Medicine
| | - Takahiro Okazaki
- Vice-Director, Shizuoka Medical Center, National Hospital Organization
| | - Mitsuho Onimaru
- Division of Pathophysiological and Experimental Pathology, Department of Pathology, Graduate School of Medical Sciences, Kyushu University
| | - Tamihiro Kawakami
- Division of Dermatology, Tohoku Medical and Pharmaceutical University
| | - Reiko Kinouchi
- Medicine and Engineering Combined Research Institute, Asahikawa Medical University.,Department of Ophthalmology, Asahikawa Medical University
| | - Atsushi Kurata
- Department of Molecular Pathology, Tokyo Medical University
| | | | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Eiichi Suematsu
- Division of Internal Medicine and Rheumatology, National Hospital Organization, Kyushu Medical Center
| | - Eijun Sueyoshi
- Department of Radiological Science, Nagasaki University Graduate School of Biomedical Sciences
| | - Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Mitsuhiro Takeno
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University Faculty of Medicine
| | | | - Hiroaki Dobashi
- Division of Hematology, Rheumatology and Respiratory Medicine Department of Internal Medicine, Faculty of Medicine, Kagawa University
| | - Yoshikazu Nakaoka
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute
| | - Kenji Nagasaka
- Department of Rheumatology, Ome Municipal General Hospital
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University
| | | | - Shoichi Ozaki
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Hiroshi Shigematsu
- Clinical Research Center for Medicine, International University of Health and Welfare
| | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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20
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Adami G, Fassio A, Rossini M, Caimmi C, Giollo A, Orsolini G, Viapiana O, Gatti D. Osteoporosis in Rheumatic Diseases. Int J Mol Sci 2019; 20:E5867. [PMID: 31766755 PMCID: PMC6928928 DOI: 10.3390/ijms20235867] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/16/2019] [Accepted: 11/21/2019] [Indexed: 12/17/2022] Open
Abstract
Osteoporosis is a chronic disease characterized by an increased risk of fragility fracture. Patients affected by rheumatic diseases are at greater risk of developing osteoporosis. The purpose of the present review is to discuss the pathogenesis, epidemiology, and treatment of osteoporosis in patients affected by rheumatic diseases with special focus for rheumatoid arthritis, psoriatic arthritis, spondyloarthritis, systemic lupus erythematosus, systemic sclerosis, vasculitides, Sjogren syndrome, and crystal-induced arthritis.
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Affiliation(s)
- Giovanni Adami
- Rheumatology Unit, University of Verona, Policlinico Borgo Roma, Pz Scuro 10, 37134 Verona, Italy; (A.F.); (M.R.); (C.C.); (A.G.); (G.O.); (O.V.); (D.G.)
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21
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Maillet T, Goletto T, Beltramo G, Dupuy H, Jouneau S, Borie R, Crestani B, Cottin V, Blockmans D, Lazaro E, Naccache JM, Pugnet G, Nunes H, de Menthon M, Devilliers H, Bonniaud P, Puéchal X, Mouthon L, Bonnotte B, Guillevin L, Terrier B, Samson M. Usual interstitial pneumonia in ANCA-associated vasculitis: A poor prognostic factor. J Autoimmun 2019; 106:102338. [PMID: 31570253 DOI: 10.1016/j.jaut.2019.102338] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Progressive fibrosing interstitial lung disease (ILD) is rarely associated with antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). This study focused on the outcomes of ILD patients with associated AAV (AAV-ILD). METHODS AAV-ILD (cases: microscopic polyangiitis (MPA) or granulomatosis with polyangiitis (GPA) with ILD) were compared to AAV patients without ILD (controls). ILD was defined as a usual interstitial pneumonia (UIP) or non-specific interstitial pneumonia (NSIP) pattern. Two controls were matched to each case for age (>or ≤65 years), ANCA status (PR3-or MPO-positive) and creatininemia (≥or <150 μmol/L). RESULTS Sixty-two cases (89% MPO-ANCA+) were included. Median age at AAV diagnosis was 66 years. ILD (63% UIP), was diagnosed before (52%) or simultaneously (39%) with AAV. Cases versus 124 controls less frequently had systemic vasculitis symptoms. One-, 3- and 5-year overall survival rates, respectively, were: 96.7%, 80% and 66% for cases versus 93.5%, 89.6% and 83.8% for controls (p = 0.008). Multivariate analyses retained age >65 years (hazard ratio (HR) 4.54; p < 0.001), alveolar haemorrhage (HR 2.25; p = 0.019) and UIP (HR 2.73; p = 0.002), but not immunosuppressant use, as factors independently associated with shorter survival. CONCLUSION For AAV-ILD patients, only UIP was associated with poorer prognosis. Immunosuppressants did not improve the AAV-ILD prognosis. But in analogy to idiopathic pulmonary fibrosis, anti-fibrosing agents might be useful and should be assessed in AAV-ILD patients with a UIP pattern.
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Affiliation(s)
- Thibault Maillet
- Department of Internal Medicine and Clinical Immunology, CHU Dijon Bourgogne, Dijon, France
| | - Tiphaine Goletto
- Department of Pulmonology, Hôpital Saint-Louis, APHP, Paris, France
| | - Guillaume Beltramo
- Respiratory and ICU Department, Referral Center for Adults Rare Pulmonary Diseases, Inserm 1231, CHU Dijon-Bourgogne, Dijon, France
| | - Henry Dupuy
- Department of Internal Medicine and Infectious Diseases, Hôpital Haut-Lévêque, Bordeaux, France
| | - Stéphane Jouneau
- Department of Pulmonology, Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), UMR S, 1085, Rennes, France
| | - Raphael Borie
- Department of Pulmonology, Hôpital Bichat, APHP, Paris, France
| | - Bruno Crestani
- Department of Pulmonology, Hôpital Bichat, APHP, Paris, France
| | - Vincent Cottin
- Department of Pulmonology, Hôpital Louis-Pradel, Bron, France
| | - Daniel Blockmans
- Department of Internal Medicine, UZ Leuven Hospital, Leuven, Belgium
| | - Estibaliz Lazaro
- Department of Internal Medicine and Infectious Diseases, Hôpital Haut-Lévêque, Bordeaux, France
| | - Jean-Marc Naccache
- Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Tenon, Service de Pneumologie, Site Constitutif Du Centre de Référence des Maladies Pulmonaires Rares OrphaLung, Paris, France
| | - Grégory Pugnet
- Department of Internal Medicine, CHU de Toulouse, Toulouse, France
| | - Hilario Nunes
- Department of Pulmonology, Hôpital Avicenne, APHP, Bobigny, France
| | - Mathilde de Menthon
- Department of Internal Medicine, Hôpital Bicêtre, APHP, Le Kremlin-Bicêtre, France
| | - Hervé Devilliers
- Department of Internal Medicine and Systemic Diseases, CHU Dijon-Bourgogne, Dijon, France
| | - Philippe Bonniaud
- Respiratory and ICU Department, Referral Center for Adults Rare Pulmonary Diseases, Inserm 1231, CHU Dijon-Bourgogne, Dijon, France
| | - Xavier Puéchal
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, APHP, Inserm U1016, Université Paris Descartes, Paris, France
| | - Luc Mouthon
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, APHP, Inserm U1016, Université Paris Descartes, Paris, France
| | - Bernard Bonnotte
- Department of Internal Medicine and Clinical Immunology, CHU Dijon Bourgogne, Dijon, France
| | - Loïc Guillevin
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, APHP, Inserm U1016, Université Paris Descartes, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, APHP, Inserm U1016, Université Paris Descartes, Paris, France
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, CHU Dijon Bourgogne, Dijon, France
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Abstract
Polyarteritis nodosa (PAN) is a necrotizing arteritis of medium-sized vessels, which is often fatal if untreated. It frequently affects the skin (nodules and ulcers), the peripheral nervous system (mononeuritis multiplex) and the visceral vessels (stenoses and microaneurysms). The complex diagnostic work-up requires discriminating PAN from infectious, malignant, drug-induced and other inflammatory conditions. It can be subclassified into further variants (idiopathic, associated with hepatitis B, associated with hereditary inflammatory diseases or isolated cutaneous disease). While idiopathic and hereditary inflammatory variants require immunosuppressive treatment, the hepatitis B-associated variant is treated with virustatic agents and plasmapheresis. The isolated cutaneous variant has a good prognosis and rarely requires highly potent immunosuppressives.
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Pagnoux C, Mendel A. Treatment of systemic necrotizing vasculitides: recent advances and important clinical considerations. Expert Rev Clin Immunol 2019; 15:939-949. [DOI: 10.1080/1744666x.2019.1656527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Christian Pagnoux
- Vasculitis Clinic, Division of Rheumatology, Mount Sinai Hospital, University Health Network, Toronto, Ontario, Canada
- Canadian Vasculitis research network (CanVasc), Canada
| | - Arielle Mendel
- Vasculitis Clinic, Division of Rheumatology, Mount Sinai Hospital, University Health Network, Toronto, Ontario, Canada
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Hogan SL, Nachman PH, Poulton CJ, Hu Y, Blazek LN, Free ME, Jennette JC, Falk RJ. Understanding Long-term Remission Off Therapy in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Kidney Int Rep 2019; 4:551-560. [PMID: 30993230 PMCID: PMC6451087 DOI: 10.1016/j.ekir.2019.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 12/03/2018] [Accepted: 01/07/2019] [Indexed: 10/29/2022] Open
Abstract
Introduction In antineutrophil cytoplasmic antibody-associated (ANCA) vasculitis, relapse risk and long-term immunosuppressive therapy are problematic. Stopping immunotherapy has not been well described. Methods The Glomerular Disease Collaborative Network ANCA vasculitis inception cohort was evaluated. Patients who stopped all immunotherapy and those continuously on immunotherapy (≥2 years) were included. Time to first period off therapy was modeled with end-stage kidney disease and death as competing risks to understand influences of stopping therapy. Cause-specific hazard ratios (HRs) with 95% confidence intervals (CI) and P values are reported. Models controlled for age, sex, ANCA specificity, organ involvement, diagnosis era, and treatments (yes/no). Repeated events analysis was used to assess the time-dependent variable of time off treatment on recurrent relapse with HRs, 95% CIs, and P values are reported (same control variables without treatments). Results In 427 patients, 277 (65%) stopped therapy (median 20 months from initial induction); 14% for ≥2 different periods of time and 23% for periods ≥5 years. In multivariable models of time to discontinuation of treatment, women (HR 1.33; 95% CI 1.04-1.70; P = 0.024) and those treated with pulse methylprednisolone (HR 1.39; 95% CI 1.05-1.84; P = 0.020) were more likely to stop. The time-dependent variable of time off treatment was associated with fewer recurrent relapses (HR 0.51; 95% CI 0.41-0.63; P < 0.001). Conclusions Stopping immunotherapy was common. Women and those treated with methylprednisolone stop treatment more often, but underlying mechanisms are unknown. Stopping treatment was associated with fewer relapses, suggesting that even without guidelines there may be benefits without an untoward detriment of relapse.
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Affiliation(s)
- Susan L Hogan
- Division of Nephrology, Department of Medicine, and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Patrick H Nachman
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Caroline J Poulton
- Division of Nephrology, Department of Medicine, and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Yichun Hu
- Division of Nephrology, Department of Medicine, and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Lauren N Blazek
- Division of Nephrology, Department of Medicine, and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Meghan E Free
- Division of Nephrology, Department of Medicine, and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - J Charles Jennette
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Ronald J Falk
- Division of Nephrology, Department of Medicine, and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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25
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Abstract
Polyarteritis nodosa (PAN) is a necrotizing vasculitis affecting medium-sized vessels whose main manifestations are weight loss, fever, peripheral neuropathy, renal, musculoskeletal, gastrointestinal tract and/or cutaneous involvement(s), hypertension and/or cardiac failure. Peripheral neuropathy is one of the most frequent and earliest symptoms, affecting 50% to 75% of PAN patients. Central nervous system involvement affects only 2% to 10% of PAN patients, often late during the disease course. Treatment relies on combining corticosteroids and an immunosuppressant (mainly cyclophosphamide) in patients with poor prognoses. In patients with hepatitis B virus-related PAN, plasma exchanges and antiviral drugs should be combined with corticosteroids.
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Affiliation(s)
- Hubert de Boysson
- Department of Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Loïc Guillevin
- Vasculitides and Scleroderma, Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Université Paris Descartes, 27, rue Fg Saint-Jacques, Paris 75679 Cedex 14, France.
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Jardel S, Puéchal X, Le Quellec A, Pagnoux C, Hamidou M, Maurier F, Aumaitre O, Aouba A, Quemeneur T, Subra JF, Cottin V, Sibilia J, Godmer P, Cacoub P, Fauchais AL, Hachulla E, Maucort-Boulch D, Guillevin L, Lega JC. Mortality in systemic necrotizing vasculitides: A retrospective analysis of the French Vasculitis Study Group registry. Autoimmun Rev 2018; 17:653-659. [PMID: 29730524 DOI: 10.1016/j.autrev.2018.01.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/07/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of the study was to describe the evolution of mortality and cause-specific mortality over time in patients with systemic necrotizing vasculitides (SNV), including polyarteritis nodosa (PAN), granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). METHODS Patients with SNV from the French Vasculitis Study Group registry were divided into 5 groups according to the date of diagnosis: <1980, 1980-1989, 1990-1999, 2000-2010, and ≥ 2010. The causes of death were classified as vasculitis, infection, cardiovascular, malignancy, miscellaneous, or unknown. RESULTS Among the 2217 patients included (PAN 16.1%, GPA 41.7%, EGPA 22.6%, MPA 19.6%), overall incidence of death was 2.26 per 100 person-years. The overall survival improved during each period considered. The 5-year survival rate increased from 72.2% (95% confidence interval [CI] 59.7-87.2) for patients diagnosed before 1980 to 94.5% (95% CI 90.4-98.8) after 2010 (p < 0.001). Periods of diagnosis, age, and male gender were independently associated with a poor survival with a non-significant difference between vasculitis. The incidence of mortality between the 1980s and after 2010 significantly decreased for vasculitis-related (p = 0.03) and cardiovascular-related deaths (p = 0.04). Incidence of death by infection remained stable between the 1980s and the 2000s but no death by infection occurred after 2010. The incidence of death by malignancy remained stable over time. CONCLUSION Overall survival of SNV patients has improved since the 1980s with the decrease of vasculitis- and cardiovascular-related deaths, but cancer-related mortality remained stable. These results highlight malignancy as the current target to improve the overall prognosis.
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Affiliation(s)
- Sabine Jardel
- National Referral Centre for rare Juvenile Rheumatological and Autoimmune Diseases, Department of Internal and Vascular Medicine, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, CNRS, Claude Bernard University Lyon 1, Lyon, France
| | - Xavier Puéchal
- National Referral Centre for rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Public - Hôpitaux de Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Alain Le Quellec
- Department of Internal Medicine, Centre Hospitalier Régional Universitaire de Montpellier, Hôpital St. Eloi, Montpellier 1 University, Montpellier, France
| | - Christian Pagnoux
- National Referral Centre for rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Public - Hôpitaux de Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Mohamed Hamidou
- Department of Internal Medicine, Centre Hospitalier Universitaire Hôtel-Dieu, Nantes, France
| | - François Maurier
- Department of Internal medicine and Clinical Immunology, Site Belle Isle, Metz, France
| | - Olivier Aumaitre
- Department of Internal Medicine, Centre Hospitalier Universitaire, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Achille Aouba
- Department of Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen University, Caen, France
| | - Thomas Quemeneur
- Department of Internal Medicine, Centre Hospitalier, Valenciennes, France
| | - Jean-François Subra
- Department of Internal Medicine, Centre Hospitalier Universitaire d' Angers, Angers, France
| | - Vincent Cottin
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Lyon, France
| | - Jean Sibilia
- Department of Rheumatology, National Reference Center for rare Systemic Autoimmune Diseases, Strasbourg University Hospital, Strasbourg University, Strasbourg, France
| | - Pascal Godmer
- Department of Internal Medicine, Centre Hospitalier Bretagne-Atlantique, Vannes, France
| | - Patrice Cacoub
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), F-75005, Paris, France; INSERM, UMRS 959, F-75013, Paris, France; CNRS, FRE3632, F-75005, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, F-75013, Paris, France
| | - Anne Laure Fauchais
- Department of Internal Medicine, Hôpital Dupuytren, Centre Hospitalier Universitaire de Limoges Limoges University, Limoges, France
| | - Eric Hachulla
- Department of Internal Medicine, Hôpital Claude Huriez, University of Lille, Lille, France
| | - Delphine Maucort-Boulch
- Department of Biostatistics and bioinformatics, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon Claude Bernard University Lyon 1, Lyon, France
| | - Loïc Guillevin
- National Referral Centre for rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Public - Hôpitaux de Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Jean-Christophe Lega
- National Referral Centre for rare Juvenile Rheumatological and Autoimmune Diseases, Department of Internal and Vascular Medicine, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, CNRS, Claude Bernard University Lyon 1, Lyon, France.
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Abstract
Vasculitides are disorders characterized by inflammation of the vessel walls, often caused by autoimmunity, but sometimes as a result of microbial invasion. Almost all types of microbes including bacteria, viruses, protozoa and fungi have been incriminated in the pathogenesis of vasculitis. Accurate etiological diagnosis is important since immunosuppressive treatment may lead to further deterioration if infection is the cause of vasculitis. Clinical features sometimes provide clues to the etiology. Further evaluation requires a focused and cost-effective plan of laboratory investigation. The investigations aim at establishing the diagnosis of vasculitis and identify the causative organism. An accurate diagnosis of vasculitis optimally requires histological examination and imaging. For infection-associated vasculitis, the identification of the organism requires studies of stained specimens, cultures, and/or detection of antigens and antibodies. Ideally, the treatment involves administration of an appropriate antimicrobial. In non-self-limiting types of vasculitides, glucocorticoids are needed when the symptoms are progressive, with vital organs involvement, and sometimes, when there is no antimicrobial agent of proven efficacy against the incriminated agent. Additional immunosuppressive agents or interventions must be considered when the disease is severe and/or post-infective immune mechanisms are involved in the pathogenesis, e.g., severe HBV- or HCV-associated vasculitides. Available preventative vaccinations are also crucial. The incidence of HBV-associated vasculitides dramatically decreased following HBV vaccination campaigns, and other infection-associated vasculitides may as well in the future.
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Affiliation(s)
- Syed A Haq
- BSM Medical University, Dhaka, Bangladesh
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28
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Conventional and biological immunosuppressants in vasculitis. Best Pract Res Clin Rheumatol 2018; 32:94-111. [DOI: 10.1016/j.berh.2018.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/18/2018] [Accepted: 07/09/2018] [Indexed: 12/20/2022]
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Puéchal X, Pagnoux C, Baron G, Quémeneur T, Néel A, Agard C, Lifermann F, Liozon E, Ruivard M, Godmer P, Limal N, Mékinian A, Papo T, Ruppert AM, Bourgarit A, Bienvenu B, Geffray L, Saraux JL, Diot E, Crestani B, Delbrel X, Sailler L, Cohen P, Le Guern V, Terrier B, Groh M, Le Jeunne C, Mouthon L, Ravaud P, Guillevin L. Adding Azathioprine to Remission-Induction Glucocorticoids for Eosinophilic Granulomatosis With Polyangiitis (Churg-Strauss), Microscopic Polyangiitis, or Polyarteritis Nodosa Without Poor Prognosis Factors: A Randomized, Controlled Trial. Arthritis Rheumatol 2017; 69:2175-2186. [PMID: 28678392 DOI: 10.1002/art.40205] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 06/29/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE In most patients with nonsevere systemic necrotizing vasculitides (SNVs), remission is achieved with glucocorticoids alone, but one-third experience a relapse within 2 years. This study was undertaken to determine whether the addition of azathioprine (AZA) to glucocorticoids could achieve a higher sustained remission rate of newly diagnosed nonsevere eosinophilic granulomatosis with polyangiitis (Churg-Strauss) (EGPA), microscopic polyangiitis (MPA), or polyarteritis nodosa (PAN). METHODS All patients included in this double-blind trial received glucocorticoids, gradually tapered over 12 months, and were randomized to receive AZA or placebo for 12 months, with stratification according to SNV (EGPA or MPA/PAN). The primary end point was the combined rate of remission induction failures and minor or major relapses at month 24. RESULTS Ninety-five patients (51 with EGPA, 25 with MPA, and 19 with PAN) met the inclusion criteria, were randomized, and received at least 1 dose of AZA (n = 46) or placebo (n = 49). At month 24, 47.8% of the patients receiving AZA versus 49% of the patients receiving placebo had remission induction failures or relapses (P = 0.86). Secondary end points were comparable between the AZA and placebo arms. These included initial remission rate (95.7% versus 87.8%), total relapse rate (44.2% versus 40.5%), and glucocorticoid use. Two patients in the placebo arm died; 22 patients in the AZA arm (47.8%) and 23 patients in the placebo arm (46.9%) experienced ≥1 severe adverse event. For EGPA patients, the primary end point (48% in the AZA arm versus 46.2% in the placebo arm) and the percent of patients who experienced asthma/rhinosinusitis exacerbations (24% in the AZA arm versus 19.2% in the placebo arm) were comparable between treatment arms. CONCLUSION Addition of AZA to glucocorticoids for the induction of remission of nonsevere SNVs does not improve remission rates, lower relapse risk, spare steroids, or diminish the EGPA asthma/rhinosinusitis exacerbation rate.
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Affiliation(s)
- Xavier Puéchal
- National Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Université Paris Descartes, Hôpital Cochin, AP-HP, Paris, France
| | - Christian Pagnoux
- National Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Université Paris Descartes, Hôpital Cochin, AP-HP, Paris, France
| | - Gabriel Baron
- Université Paris Descartes, Hôtel-Dieu, AP-HP, Paris, France
| | | | - Antoine Néel
- Centre Hospitalier Universitaire Hôtel-Dieu, Nantes, France
| | | | | | - Eric Liozon
- Centre Hospitalier Universitaire Dupuytren, Limoges, France
| | - Marc Ruivard
- Centre Hospitalier Universitaire Estaing, Clermont-Ferrand, France
| | - Pascal Godmer
- Centre Hospitalier Bretagne Atlantique, Vannes, France
| | - Nicolas Limal
- Hôpital Henri-Mondor, Université Paris-Est Créteil, AP-HP, Créteil, France
| | - Arsène Mékinian
- Hôpital Saint-Antoine, Université Pierre et Marie Curie, AP-HP, Paris, France
| | - Thomas Papo
- Hôpital Bichat-Claude-Bernard, Université Denis-Diderot, AP-HP, Paris, France
| | | | - Anne Bourgarit
- Hôpital Jean-Verdier, Université Léonard-de-Vinci, AP-HP, Bondy, France
| | - Boris Bienvenu
- Centre Hospitalier Universitaire Côte de Nacre, Caen, France
| | | | | | | | - Bruno Crestani
- Hôpital Bichat-Claude-Bernard, Université Denis-Diderot, AP-HP, Paris, France
| | | | | | - Pascal Cohen
- National Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Université Paris Descartes, Hôpital Cochin, AP-HP, Paris, France
| | - Véronique Le Guern
- National Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Université Paris Descartes, Hôpital Cochin, AP-HP, Paris, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Université Paris Descartes, Hôpital Cochin, AP-HP, Paris, France
| | - Matthieu Groh
- National Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Université Paris Descartes, Hôpital Cochin, AP-HP, Paris, France
| | - Claire Le Jeunne
- National Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Université Paris Descartes, Hôpital Cochin, AP-HP, Paris, France
| | - Luc Mouthon
- National Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Université Paris Descartes, Hôpital Cochin, AP-HP, Paris, France
| | - Philippe Ravaud
- Université Paris Descartes, Hôtel-Dieu, AP-HP, Paris, France
| | - Loïc Guillevin
- National Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Université Paris Descartes, Hôpital Cochin, AP-HP, Paris, France
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Bischof A, Manigold T, Barro C, Heijnen I, Berger CT, Derfuss T, Kuhle J, Daikeler T. Serum neurofilament light chain: a biomarker of neuronal injury in vasculitic neuropathy. Ann Rheum Dis 2017; 77:1093-1094. [DOI: 10.1136/annrheumdis-2017-212045] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 07/12/2017] [Indexed: 11/04/2022]
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Saunier A, Issa N, Vandenhende MA, Morlat P, Doutre MS, Bonnet F. Treatment of polyarteritis nodosa with tocilizumab: a new therapeutic approach? RMD Open 2017; 3:e000446. [PMID: 28879047 PMCID: PMC5574418 DOI: 10.1136/rmdopen-2017-000446] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/08/2017] [Accepted: 05/16/2017] [Indexed: 11/04/2022] Open
Abstract
We describe the effect of interleukin 6 (IL-6) blockade using tocilizumab (TCZ) for inducing and maintaining remission of refractory polyarteritis nodosa (PAN). Three patients with refractory PAN defined according to the American College of Rheumatology criteria were treated with TCZ infusions (8 mg/kg) on a monthly basis. All of them had severe cutaneous and articular involvement with elevated biological inflammatory markers. One suffered from a neuritis multiplex and one from renal and digestive damage. All three patients were dependent on high doses of glucocorticoids (above 0.5 mg/kg) and two of them were resistant to immunosuppressive drugs. All patients achieved and maintained clinical response and normalisation of the inflammation acute-phase proteins after a few weeks of treatment with TCZ. Prednisolone could be reduced by an average of 41–13 mg/day. These first case reports suggest that IL-6 blockade using TCZ could be a therapeutic alternative to induce remission in patients with polyarteritis nodosa resistant or intolerant to the reference treatment.
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Affiliation(s)
- Aurélie Saunier
- Service de Médecine Interne et Maladies Infectieuses, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France
| | - Nahéma Issa
- Service de Médecine Interne et Maladies Infectieuses, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France
| | - Marie-Anne Vandenhende
- Service de Médecine Interne et Maladies Infectieuses, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France
| | - Philippe Morlat
- Service de Médecine Interne et Maladies Infectieuses, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France
| | - Marie-Sylvie Doutre
- Service de Dermatologie, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France
| | - Fabrice Bonnet
- Service de Médecine Interne et Maladies Infectieuses, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France
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Erden A, Batu ED, Sönmez HE, Sarı A, Armagan B, Arıcı ZS, Bilgin E, Kalyoncu U, Karadağ Ö, Bilginer Y, Ertenli AI, Özen S. Comparing polyarteritis nodosa in children and adults: a single center study. Int J Rheum Dis 2017. [PMID: 28626961 DOI: 10.1111/1756-185x.13120] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Polyarteritis nodosa (PAN) is a necrotizing vasculitis of medium/small arteries. We aimed to examine the characteristics of adult- and childhood-onset PAN. METHODS Fifteen pediatric (˂ 18 years) and 22 adult PAN patients who fulfilled the Ankara 2008 and American College of Rheumatology 1990 criteria, respectively, were included in the study. RESULTS Five children had cutaneous and all the rest of the patients had systemic PAN. Weight loss was more common (59.1% vs. 20%, P = 0.041) and presence of an angiography at diagnosis was more frequent (81.8% vs. 33.3%, P = 0.003) in adults than children. Arthralgia/arthritis and skin involvement were more common in children (86.7% vs. 59.1%; 93.3% vs. 72.7%, respectively) while renal and neurologic involvement were more frequently observed in adult patients (50% vs. 20%; 59.1% vs. 40%, respectively) (P > 0.05 for all). Cutaneous PAN patients were treated with corticosteroids only. All but one adult patient received cyclophosphamide while mycophenolate mofetil was used in five and cyclophosphamide was used in four children as induction treatment. The median duration of induction treatment was longer in adults than children (12 vs. 3 months, respectively; P = 0.004). The most common maintenance drug was mycophenolate mofetil in children and azathioprine in adults. The mortality rate was 13.6% (n = 3) and 0% in adults and children, respectively. CONCLUSION To our knowledge, this is the first study comparing characteristics of adult and childhood onset PAN. Our results have suggested that juvenile PAN had a more benign course (with less renal and neurologic involvement, shorter duration of induction treatment) than adult onset PAN.
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Affiliation(s)
- Abdulsamet Erden
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ezgi D Batu
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Hafize E Sönmez
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alper Sarı
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Berkan Armagan
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Zehra S Arıcı
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Emre Bilgin
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Umut Kalyoncu
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ömer Karadağ
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Yelda Bilginer
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ali Ihsan Ertenli
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seza Özen
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Tsurikisawa N, Oshikata C, Kinoshita A, Tsuburai T, Saito H. Longterm Prognosis of 121 Patients with Eosinophilic Granulomatosis with Polyangiitis in Japan. J Rheumatol 2017; 44:1206-1215. [PMID: 28572468 DOI: 10.3899/jrheum.161436] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2017] [Indexed: 01/15/2023]
Abstract
OBJECTIVE We investigated the risk factors for relapse or prognosis of eosinophilic granulomatosis with polyangiitis (EGPA) in Japanese patients presenting to our hospital. METHODS From June 1999 through March 2015, we retrospectively recruited 121 patients with EGPA according to the American College of Rheumatology criteria. Frequent relapse was defined as disease occurrence at least once every 2 years after a period of initial remission. The study endpoint was the last examination performed. We used multiple logistic regression to analyze risk factors for relapse or survival in EGPA. RESULTS Gastrointestinal (GI) involvement with both abnormalities on endoscopy and biopsy (p < 0.01) and symptoms; myocardial involvement with both abnormalities on 1 or more cardiac investigations and symptoms (p < 0.01); and treatment at initial or maintenance with immunosuppressants (p < 0.01) or administration of intravenous immunoglobulin (IVIG; p < 0.01) were associated significantly more often with frequent relapse than with infrequent. Overall 5-, 10-, and 20-year survival rates were 91.1%, 83.7%, and 68.6%, respectively. Survival in EGPA was associated with age of onset < 65 years. Age at onset of EGPA was the only significant predictor of survival (p < 0.01). Myocardial or GI tract involvement did not affect mortality risk. CONCLUSION Patients with myocardial or GI tract involvement had frequent relapses, but these conditions were not reflected in increased mortality. Treatment with immunosuppressants or IVIG in addition to corticosteroids might have improved the prognosis in Japanese patients with EGPA.
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Affiliation(s)
- Naomi Tsurikisawa
- From the Department of Respirology, National Hospital Organization Saitama National Hospital, Saitama; Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital, Minami-ku Sagamihara, Japan. .,N. Tsurikisawa, MD, Department of Respirology, National Hospital Organization Saitama National Hospital, and Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; C. Oshikata, MD, Department of Respirology, National Hospital Organization Saitama National Hospital, and Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; A. Kinoshita, MD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; T. Tsuburai, MD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; H. Saito, PhD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital.
| | - Chiyako Oshikata
- From the Department of Respirology, National Hospital Organization Saitama National Hospital, Saitama; Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital, Minami-ku Sagamihara, Japan.,N. Tsurikisawa, MD, Department of Respirology, National Hospital Organization Saitama National Hospital, and Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; C. Oshikata, MD, Department of Respirology, National Hospital Organization Saitama National Hospital, and Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; A. Kinoshita, MD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; T. Tsuburai, MD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; H. Saito, PhD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital
| | - Arisa Kinoshita
- From the Department of Respirology, National Hospital Organization Saitama National Hospital, Saitama; Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital, Minami-ku Sagamihara, Japan.,N. Tsurikisawa, MD, Department of Respirology, National Hospital Organization Saitama National Hospital, and Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; C. Oshikata, MD, Department of Respirology, National Hospital Organization Saitama National Hospital, and Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; A. Kinoshita, MD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; T. Tsuburai, MD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; H. Saito, PhD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital
| | - Takahiro Tsuburai
- From the Department of Respirology, National Hospital Organization Saitama National Hospital, Saitama; Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital, Minami-ku Sagamihara, Japan.,N. Tsurikisawa, MD, Department of Respirology, National Hospital Organization Saitama National Hospital, and Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; C. Oshikata, MD, Department of Respirology, National Hospital Organization Saitama National Hospital, and Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; A. Kinoshita, MD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; T. Tsuburai, MD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; H. Saito, PhD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital
| | - Hiroshi Saito
- From the Department of Respirology, National Hospital Organization Saitama National Hospital, Saitama; Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital, Minami-ku Sagamihara, Japan.,N. Tsurikisawa, MD, Department of Respirology, National Hospital Organization Saitama National Hospital, and Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; C. Oshikata, MD, Department of Respirology, National Hospital Organization Saitama National Hospital, and Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; A. Kinoshita, MD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; T. Tsuburai, MD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital; H. Saito, PhD, Department of Allergy and Respirology, National Hospital Organization Sagamihara National Hospital
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Alibaz-Oner F, Koster MJ, Crowson CS, Makol A, Ytterberg SR, Salvarani C, Matteson EL, Warrington KJ. Clinical Spectrum of Medium-Sized Vessel Vasculitis. Arthritis Care Res (Hoboken) 2017; 69:884-891. [PMID: 27564269 DOI: 10.1002/acr.23007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 07/25/2016] [Accepted: 08/09/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis of medium-sized visceral vessels. However, cutaneous arteritis (CA) and gastrointestinal (GI) vasculitis are forms of single-organ vasculitis having indistinguishable histopathologic findings from PAN. The aim of this study was to evaluate and compare the clinical characteristics, treatment, and outcomes of patients with systemic PAN, CA, and GI vasculitis. METHODS Retrospective cohorts were assembled, consisting of patients with PAN, CA, and GI vasculitis between 1980 and 2014. The demographics, clinical characteristics, treatment, and outcomes of patients were abstracted from medical records. RESULTS We included 48 patients with PAN, 41 patients with CA, and 19 patients with GI vasculitis. The disease of 1 patient evolved from CA to systemic PAN during the disease course. At diagnosis, 94% of patients with PAN, 93% of patients with CA, and 67% of patients with GI vasculitis were treated with glucocorticoids. Additional immunosuppressive agents were used in 67% of PAN, 37% of GI vasculitis, and 32% of CA cases. The 5-year cumulative relapse rate was 45.2% in CA, and only 9.6% in PAN during a followup of approximately 6 years. No deaths were observed in the CA group. The survival rate at 10 years was 66% in the PAN group and 61% in the GI vasculitis group. CONCLUSION Systemic PAN, CA, and GI vasculitis take different clinical courses and therefore may be different diseases, rather than existing on a spectrum of the same disease. Progression of CA to systemic PAN is very rare. Relapse risk is low during followup in PAN. Patients with CA have a higher relapse rate than those with systemic PAN, possibly due to less use of immunosuppressive therapy in CA.
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Affiliation(s)
| | | | | | | | | | - Carlo Salvarani
- Azienda Ospedaliera Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy
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Martinez AR, Faber I, Nucci A, Appenzeller S, França MC. Autoimmune neuropathies associated to rheumatic diseases. Autoimmun Rev 2017; 16:335-342. [DOI: 10.1016/j.autrev.2017.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 12/06/2016] [Indexed: 12/11/2022]
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Oh YJ, Ahn SS, Park ES, Jung SM, Song JJ, Park YB, Lee SW. Birmingham vasculitis activity score at diagnosis is a significant predictor of relapse of polyarteritis nodosa. Rheumatol Int 2017; 37:685-694. [PMID: 28341881 DOI: 10.1007/s00296-017-3706-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/16/2017] [Indexed: 01/05/2023]
Abstract
The objective of this study was to investigate whether clinical and laboratory data, Birmingham vasculitis activity score (BVAS) and five factor scores (FFS) at diagnosis could predict relapse in 30 patients with polyarteritis nodosa (PAN) having the follow-up duration for over 12 months. We reviewed the medical charts of 30 patients with PAN. We obtained clinical and laboratory data at diagnosis, and we compared them between the two groups based on relapse. The optimal cut-off values of BVAS and FFS (1996) at diagnosis to predict relapse were extrapolated. The mean age of patients (15 men) was 50.8 years, and the mean follow-up duration was 64.1 months. Nine patients (30.0%) had experience relapse after remission. Patients having relapse showed the higher frequency of weight loss and ocular symptoms and the less frequency of diastolic hypertension than those having not (p < 0.005 for all). On multivariate logistic regression analysis, weight loss was the only independent predictor of relapse, but on Cox Hazard model analysis, its statistical significance disappeared. The mean initial BVAS and FFS (1996) of patients in relapse group were higher than those of patients in no relapse group (p < 0.005 for all). Patients having initial BVAS over 13.5 and FFS (1996) over 1 exhibited significantly higher risk of relapse than those having not (RR 40.0 and RR 7.0, respectively). However, initial BVAS over 13.5 only remained significant in Kaplan-Meier survival analysis. In conclusion, BVAS over 13.5 at diagnosis was the only independent predictor of relapse of PAN.
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Affiliation(s)
- Yoon-Jeong Oh
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Sung Soo Ahn
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Eun Seong Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Seung Min Jung
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea.
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Abstract
Systemic vasculitides are caused by inflammation of blood vessels and can affect any organ and any part of the gastrointestinal tract, hepatic and biliary system, as well as the pancreas. These disorders can cause a wide array of gastrointestinal manifestations, from asymptomatic elevated transaminase levels and mild abdominal pain to potentially life-threatening bowel perforations and peritonitis. A diagnosis based solely on gastrointestinal symptoms is challenging as these manifestations are not specific. Conversely, diagnostic and therapeutic delays can be rapidly detrimental. In this article, we review the epidemiology, characteristics and management of the main gastrointestinal manifestations of systemic vasculitides, including polyarteritis nodosa and antineutrophil cytoplasm antibody-associated vasculitides, as well as isolated vasculitides limited to the gastrointestinal tract.
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Koster MJ, Warrington KJ. Vasculitis of the mesenteric circulation. Best Pract Res Clin Gastroenterol 2017; 31:85-96. [PMID: 28395792 DOI: 10.1016/j.bpg.2016.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 12/09/2016] [Accepted: 12/17/2016] [Indexed: 01/31/2023]
Abstract
Vasculitis of the mesenteric circulation is an uncommon but life-threatening manifestation of systemic vasculitis. Initial symptoms are frequently non-specific and therefore patients often present to primary care physicians and gastroenterologists with abdominal pain or gastrointestinal bleeding. Given the severity of the conditions associated with mesenteric vasculitis, it is imperative to appropriately diagnose and initiate treatment of suspected cases. This review will focus on diseases commonly associated with vasculitis of the mesenteric vessels. Imaging characteristics and clinical features assisting in diagnosis as well as initial approaches to treatment are emphasized.
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Affiliation(s)
- Matthew J Koster
- Division of Rheumatology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
| | - Kenneth J Warrington
- Division of Rheumatology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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Sharma A, Pinto B, Dhooria A, Rathi M, Singhal M, Dhir V, Sharma K, Parkash M, Modi M, Vijayvergiya R, Sinha SK, Nada R, Minz RW, Singh S. Polyarteritis nodosa in north India: clinical manifestations and outcomes. Int J Rheum Dis 2016; 20:390-397. [PMID: 27990777 DOI: 10.1111/1756-185x.12954] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE There has been a significant decrease in the number of published reports of classical polyarteritis nodosa (PAN) in the post-Chapel Hill consensus conference (CHCC) nomenclature era with only two series published from Asia. We report a case series of PAN from north India. PATIENTS AND METHODS A retrospective study of all patients diagnosed to have PAN according to American College of Rheumatology criteria/CHCC nomenclature. The details of clinical presentation, investigation findings, treatment details and outcomes were noted from the records. These findings between the hepatitis B positive and negative groups were compared. RESULTS Twenty-seven patients (20 male, seven female) were diagnosed as having PAN, out of which seven (25.9%) were hepatitis B surface antigen positive. Nervous system involvement was most common with 24 patients (88.9%) having mononeuritis multiplex. Weight loss was present in 20 (74%), fever in 14 (51.9%), renal involvement in 16 (59.3%), cutaneous in nine (33.3%), peripheral gangrene in eight (29.6%), gastrointestinal (GI) involvement in eight (29.6%), testicular pain in 6/20 (30%) and cardiac involvement in four (14.8%). Twenty-three (85.2%) patients recovered, three died (11.1%) and one was lost to follow-up. Median follow-up duration was 37 (interquartile range 22.00-69.75) months. The cumulative survival was 114.16 months (95% CI: 98.27-129.95). There was no significant difference in five factor score (FFS) or revised FFS between those patients who died and those who survived (P = 0.248, 0.894, respectively). Hepatitis B-related PAN had a lower FFS compared to non-hepatitis B-related PAN (P = 0.039). No other significant differences were noted between the two groups. CONCLUSION In comparison to classic PAN in other populations, classic PAN in north India is associated with higher neurological involvement and lower GI involvement.
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Affiliation(s)
- Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Benzeeta Pinto
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aadhaar Dhooria
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manphool Singhal
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kusum Sharma
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mahesh Parkash
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Modi
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Vijayvergiya
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj K Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ranjana Walkar Minz
- Department of Immunopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Pagnoux C. Updates in ANCA-associated vasculitis. Eur J Rheumatol 2016; 3:122-133. [PMID: 27733943 PMCID: PMC5058451 DOI: 10.5152/eurjrheum.2015.0043] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 07/13/2015] [Indexed: 12/15/2022] Open
Abstract
Antineutrophil cytoplasm antibody (ANCA)-associated vasculitides are small-vessel vasculitides that include granulomatosis with polyangiitis (formerly Wegener's granulomatosis), microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Renal-limited ANCA-associated vasculitides can be considered the fourth entity. Despite their rarity and still unknown cause(s), research pertaining to ANCA-associated vasculitides has been very active over the past decades. The pathogenic role of antimyeloperoxidase ANCA (MPO-ANCA) has been supported using several animal models, but that of antiproteinase 3 ANCA (PR3-ANCA) has not been as strongly demonstrated. Moreover, some MPO-ANCA subsets, which are directed against a few specific MPO epitopes, have recently been found to be better associated with disease activity, but a different method than the one presently used in routine detection is required to detect them. B cells possibly play a major role in the pathogenesis because they produce ANCAs, as well as neutrophil abnormalities and imbalances in different T-cell subtypes [T helper (Th)1, Th2, Th17, regulatory cluster of differentiation (CD)4+ CD25+ forkhead box P3 (FoxP3)+ T cells] and/or cytokine-chemokine networks. The alternative complement pathway is also involved, and its blockade has been shown to prevent renal disease in an MPO-ANCA murine model. Other recent studies suggested strongest genetic associations by ANCA type rather than by clinical diagnosis. The induction treatment for severe granulomatosis with polyangiitis and microscopic polyangiitis is relatively well codified but does not (yet) really differ by precise diagnosis or ANCA type. It comprises glucocorticoids combined with another immunosuppressant, cyclophosphamide or rituximab. The choice between the two immunosuppressants must consider the comorbidities, past exposure to cyclophosphamide for relapsers, plans for pregnancy, and also the cost of rituximab. Once remission is achieved, maintenance strategy following cyclophosphamide-based induction relies on less toxic agents such as azathioprine or methotrexate. The optimal maintenance strategy following rituximab-based induction therapy remains to be determined. Preliminary results on rituximab for maintenance therapy appear promising. Efforts are still under way to determine the optimal duration of maintenance therapy, ideally tailored according to the characteristics of each patient and the previous treatment received.
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Affiliation(s)
- Christian Pagnoux
- Department of Medicine, Division of Rheumatology, Vasculitis Clinic, Mount Sinai Hospital, University Health Network, University of Toronto, Ontario, Canada
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Puéchal X, Pagnoux C, Perrodeau É, Hamidou M, Boffa JJ, Kyndt X, Lifermann F, Papo T, Merrien D, Smail A, Delaval P, Hanrotel-Saliou C, Imbert B, Khouatra C, Lambert M, Leské C, Ly KH, Pertuiset E, Roblot P, Ruivard M, Subra JF, Viallard JF, Terrier B, Cohen P, Mouthon L, Le Jeunne C, Ravaud P, Guillevin L. Long-Term Outcomes Among Participants in the WEGENT Trial of Remission-Maintenance Therapy for Granulomatosis With Polyangiitis (Wegener's) or Microscopic Polyangiitis. Arthritis Rheumatol 2016; 68:690-701. [PMID: 26473755 DOI: 10.1002/art.39450] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 09/24/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Findings from the WEGENT trial and other short-term studies have suggested that azathioprine (AZA) or methotrexate (MTX) could effectively maintain remission of granulomatosis with polyangiitis (Wegener's) (GPA) or microscopic polyangiitis (MPA). This study was undertaken to examine whether differences in rates of relapse or adverse events would appear after discontinuation of these 2 maintenance regimens, when assessed over a longer followup period. METHODS Long-term outcomes in patients enrolled in the WEGENT trial were analyzed according to their randomized treatment group (AZA or MTX). Parameters at trial entry were evaluated as potential prognostic factors for death, relapse, or damage in multivariate models. RESULTS Data from 10 years of followup were available for 112 (88.8%) of the 126 original trial participants. The median followup time was 11.9 years (95% confidence interval [95% CI] 11.3-12.5 years). In patients receiving AZA and those receiving MTX, the 10-year overall survival rates were 75.1% (95% CI 64.8-86.9%) and 79.9% (95% CI 70.3-90.8%) (P = 0.56), respectively, and relapse-free survival rates were 26.3% (95% CI 17.3-40.1%) and 33.5% (95% CI 23.5-47.7%) (P = 0.29), respectively. No between-treatment differences were observed with regard to rates of relapse, adverse events, damage, survival without severe side effects, and survival without relapse and severe side effects. In analyses limited to the 97 patients with GPA, no between-treatment differences in survival rates were observed. The 10-year relapse-free survival rate was lower in patients with GPA than in patients with MPA. However, in the multivariate analysis, anti-proteinase 3 antineutrophil cytoplasmic antibody (ANCA) positivity, and not GPA, was retained as being independently associated with the relapse rate. CONCLUSION The results of this long-term analysis confirm that AZA and MTX are comparable treatment options for maintaining remission of GPA or MPA. Despite achieving good overall survival with these treatments, relapse rates, adverse events, and damage remain matters of concern and further studies are needed to reduce their frequency in these ANCA-associated vasculitides.
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Affiliation(s)
- Xavier Puéchal
- Université Paris Descartes and Hôpital Cochin, AP-HP, Paris, France
| | | | | | | | | | - Xavier Kyndt
- Centre Hospitalier de Valenciennes, Valenciennes, France
| | | | - Thomas Papo
- Hôpital Bichat-Claude Bernard, Paris, France
| | | | | | | | | | - Bernard Imbert
- Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | | | - Marc Lambert
- Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | | | - Kim H Ly
- Hôpital Dupuytren, Limoges, France
| | | | - Pascal Roblot
- Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | | | | | | | - Benjamin Terrier
- Université Paris Descartes and Hôpital Cochin, AP-HP, Paris, France
| | - Pascal Cohen
- Université Paris Descartes and Hôpital Cochin, AP-HP, Paris, France
| | - Luc Mouthon
- Université Paris Descartes and Hôpital Cochin, AP-HP, Paris, France
| | - Claire Le Jeunne
- Université Paris Descartes and Hôpital Cochin, AP-HP, Paris, France
| | | | - Loïc Guillevin
- Université Paris Descartes and Hôpital Cochin, AP-HP, Paris, France
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Pagnoux C, Khalidi NA. Polyarteritis nodosa – Challenges and options in management. INDIAN JOURNAL OF RHEUMATOLOGY 2015. [DOI: 10.1016/j.injr.2015.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Mekinian A, Grignano E, Braun T, Decaux O, Liozon E, Costedoat-Chalumeau N, Kahn JE, Hamidou M, Park S, Puéchal X, Toussirot E, Falgarone G, Launay D, Morel N, Trouiller S, Mathian A, Gombert B, Schoindre Y, Lioger B, De Wazieres B, Amoura Z, Buchdaul AL, Georgin-Lavialle S, Dion J, Madaule S, Raffray L, Cathebras P, Piette JC, Rose C, Ziza JM, Lortholary O, Montestruc F, Omouri M, Denis G, Rossignol J, Nimubona S, Adès L, Gardin C, Fenaux P, Fain O. Systemic inflammatory and autoimmune manifestations associated with myelodysplastic syndromes and chronic myelomonocytic leukaemia: a French multicentre retrospective study. Rheumatology (Oxford) 2015; 55:291-300. [DOI: 10.1093/rheumatology/kev294] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Indexed: 01/02/2023] Open
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Abstract
Polyarteritis nodosa (PAN) is a necrotizing vasculitis of medium size arteries that may affect various organs. The clinical appearance is very variable. The most common manifestations are of the skin, the peripheral nervous system presenting as mononeuritis multiplex and the mesenteric and renal blood vessels due to the development of stenoses and small aneurysms. Of the cases one third are estimated to be associated with hepatitis B virus (HBV). The therapy depends on the pathogenesis of the disease: primary PAN is treated with immunosuppressants, whereas patients with HBV-related PAN should receive antiviral therapy and plasmapheresis. Differentiating PAN from other forms of vasculitis can be difficult and requires complex differential diagnostics.
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Polyarteritis nodosa associated with necrosis of the tongue: a rare presentation in an adult patient. Br J Oral Maxillofac Surg 2015; 53:883-5. [PMID: 26119698 DOI: 10.1016/j.bjoms.2015.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 06/06/2015] [Indexed: 11/24/2022]
Abstract
Polyarteritis nodosa is a rare form of vasculitis of the medium-sized vessels, which leads to the formation of microaneurysms, thrombosis, organ ischaemia, and necrosis. Involvement of the oral cavity is rare. To our knowledge, this is the first case of localised polyarteritis nodosa in an adult with ulceration of the tongue and necrosis at the onset of the disease. The patient made a full recovery after the use of strong immunosuppressants.
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Abstract
PURPOSE OF REVIEW This article discusses the clinical features, pathophysiology, and management of primary and secondary acquired immune axonal neuropathies. RECENT FINDINGS Although there are many collagen vascular disorders associated with vasculitic neuropathy, a quarter of cases have been described to be due to nonsystemic vasculitis of the peripheral nervous system. Enhanced surveillance and aggressive treatment of conditions such as cryoglobulin-related vasculitic neuropathy with cyclophosphamide, rituximab, and alfa interferons has led to improved morbidity and mortality, however, many cases of immune axonal acquired neuropathy are still associated with poor outcomes. Acute motor axonal neuropathy (AMAN) and acute motor sensory axonal neuropathy (AMSAN) are well-characterized variants of Guillain-Barré syndrome. SUMMARY Characterizing the clinical and electrophysiologic phenotype can help diagnose conditions such as nonsystemic vasculitic neuropathy, AMAN, AMSAN, and immune small fiber neuropathy, while careful evaluation of systemic features is key to identifying secondary immune axonal neuropathies such as vasculitic neuropathy related to collagen vascular disease. Additional research is needed to determine the exact immune pathogenesis and optimized treatment regimens for all acquired immune axonal neuropathies.
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Flossmann O. Risks of treatments and long-term outcomes of systemic ANCA-associated vasculitis. Presse Med 2015; 44:e251-7. [DOI: 10.1016/j.lpm.2015.02.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 02/16/2015] [Indexed: 10/23/2022] Open
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