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Vogt K, Fink CB, Schreibing TM, Krämer S, Reinartz S, Rauen T. Distinct pulmonary patterns in ANCA-associated vasculitides: insights from a retrospective single center cohort study. Rheumatol Int 2024; 44:2435-2443. [PMID: 39136785 DOI: 10.1007/s00296-024-05664-8] [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: 05/15/2024] [Accepted: 07/08/2024] [Indexed: 09/26/2024]
Abstract
ANCA-associated vasculitides (AAV) comprise granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis. All forms may involve different organ systems, yet kidney and lung involvement are common and fatal in many cases. Here, we aimed to determine the predictive value of pulmonary disease manifestation and individual CT findings in AAV patients. Available CT scans and clinical information on mortality, renal outcomes, occurrence of relapses and damage scores were analysed retrospectively from a tertiary rheumatology center in Germany. We included a total of 94 AAV patients (49 with GPA, 41 with MPA). Forty-four patients had lung involvement with available CT scans, 70.5% of which with GPA and 72.7% with renal involvement. Nodule formation and cavities were more frequent among GPA patients, whereas ground-glass opacities (GGO), ILD and pleural effusion were observed predominantly in MPA patients. Over a median follow-up of 37 months, GPA patients had a slightly higher overall mortality, whereas end-stage kidney failure rates were significantly increased in MPA patients. Relapse frequencies were comparable between both entities. The presence of GGO and pleural effusion were associated with higher relapse rates, whereas nodules were negatively correlated with relapses. Notably, RTX-treated patients had less infections as compared to individuals under different therapies. Our data demonstrate the outstanding importance of characteristic CT patterns in AAV diagnosis assessment. Especially certain CT patterns including GGO and pleura effusion may help to identify patients who are at higher risk for relapsing disease.
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Affiliation(s)
- Kristian Vogt
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Christian Bijan Fink
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Düsseldorf, Germany
| | - Teresa Maria Schreibing
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Stefan Krämer
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Sebastian Reinartz
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Düsseldorf, Germany.
| | - Thomas Rauen
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
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Lee YJ, Kim HC, Ahn SM, Oh JS, Kim YG, Lee CK, Yoo B, Hong S. Progression to ANCA-associated vasculitis in patients with idiopathic interstitial pneumonia and positive ANCA. Semin Arthritis Rheum 2024; 68:152484. [PMID: 38870566 DOI: 10.1016/j.semarthrit.2024.152484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/10/2024] [Accepted: 05/28/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVE This study explored the development of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and its risk factors in patients with idiopathic interstitial pneumonia (IIP) and positive ANCA results. METHODS Data of patients diagnosed with IIP with positive ANCA results at a single tertiary center in South Korea were retrospectively reviewed from January 2013 to August 2023. Cox regression analysis was performed to identify variables associated with AAV occurrence following IIP diagnosis. Kaplan-Meier curves were employed to investigate the relationship between autoantibodies and the occurrence of AAV. RESULTS In a cohort of 154 IIP-diagnosed patients with positive ANCA results but without AAV, 10.4 % of them eventually developed AAV. The AAV and non-AAV groups did not significantly differ by sex, age, smoking status, urinalysis, or chest computed tomography findings. All the patients who subsequently developed AAV were anti-myeloperoxidase (MPO) positive, while 48.8 % of the non-AAV patients were anti-MPO positive (P < 0.001). Rheumatoid factor (RF) positivity differed significantly (62.5 % vs. 29.2 %, P = 0.007) between the AAV and non-AAV groups. Multivariate Cox regression and Kaplan-Meier analyses revealed RF (HR 4.02; P = 0.004) and anti-MPO (HR 38.10; P < 0.001) positivity as risk factors associated with AAV occurrence. CONCLUSION Approximately 10 % of ANCA-positive IIP patients developed AAV after an IIP diagnosis. Anti-MPO or co-occurring positive RF poses a significant risk for subsequent AAV occurrence. This emphasizes the importance of careful monitoring in patients with high-risk antibody profiles, even if the complete features of AAV are not present at IIP diagnosis.
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Affiliation(s)
- Yeo-Jin Lee
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ho Cheol Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Soo Min Ahn
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Seon Oh
- Department of Information Medicine, Big Data Research Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong-Gil Kim
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chang-Keun Lee
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bin Yoo
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seokchan Hong
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Bhandari K, Shah SK, Ghimire S, Shah A, Yadav RK. Takayasu arteritis and interstitial lung disease: a case report and literature review. Ann Med Surg (Lond) 2024; 86:6303-6310. [PMID: 39359814 PMCID: PMC11444634 DOI: 10.1097/ms9.0000000000002544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 08/26/2024] [Indexed: 10/04/2024] Open
Abstract
Introduction and importance Although pulmonary artery involvement is well recognized, the incidence of interstitial lung disease (ILD) with Takayasu arteritis is very rare. The pathophysiology of ILD in Takayasu is still incompletely understood, in contrast to several studies establishing the relationship between ANCA-associated vasculitis and ILD. The management of this patient involved a multidisciplinary approach with long-term follow-up. Case presentation The authors present a case of HRCT-proven interstitial lung disease in a patient with Takayasu arteritis and heart failure. The patient was on long-term corticosteroids on and off for several years and recently developed progressive dyspnea with a dry cough. After reviewing her history and physical examination, pulmonary function tests (PFTs) and high-resolution computed tomography (HRCT) were performed, and interstitial lung disease was diagnosed. The patient was managed by a team of pulmonologists, rheumatologists, and cardiologists and gradually improved after adjustment of medications, including corticosteroids and mycofenolate, and via long-term oxygen therapy. Clinical discussion Takayasu arteritis is a rare form of systemic vasculitis that can involve the pulmonary vasculature, such vasculitis with associated parenchymal involvement is rare. ILDs have been demonstrated with ANCA-associated vasculitis; however, whether the pathophysiology applies to Takayasu is unknown. Since Takayasu can be debilitating to the patient, the association of ILDs can have further prognostic implications. Given that no established guidelines exist to address this association, management is based on clinical expertise. Conclusion The authors report a case of Takayasu arteritis and associated ILD and its pharmacological management. Takayasu arteritis is a very uncommon type of vasculitis, and pulmonary parenchymal involvement further contributes to this case's rarity. As the management of Takayasu arteritis alone is cumbersome, the addition of another significant comorbidity, such as ILD, can pose several threats to the patient. Given the rarity of this association, no established guidelines exist, making clinical expertise crucial for managing such patients. Further research is needed to explore the underlying mechanisms and develop evidence-based treatment strategies for this rare combination.
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Affiliation(s)
- Kritick Bhandari
- KIST Medical College and Teaching Hospital, Gwarko, Imadol, Lalitpur, Nepal
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4
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Atzeni F, Alciati A, Gozza F, Masala IF, Siragusano C, Pipitone N. Interstitial lung disease in rheumatic diseases: an update of the 2018 review. Expert Rev Clin Immunol 2024:1-18. [PMID: 39302018 DOI: 10.1080/1744666x.2024.2407536] [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: 07/20/2023] [Revised: 07/25/2024] [Accepted: 09/18/2024] [Indexed: 09/22/2024]
Abstract
INTRODUCTION Interstitial lung disease (ILD) is a potential severe complication of various rheumatic diseases, typically connective tissue diseases (CTD), associated with significant morbidity and mortality. ILD may occur during the course of the disease but may also be its first manifestation. Several cell types are involved in ILD's pathogenesis, and if not controlled, pulmonary inflammation may lead to pulmonary fibrosis. AREAS COVERED We searched PubMed, Medline, and the Cochrane Library for papers published between 1995 and February 2017 in the first version, and between 2017 and April 2023 using combinations of words. The most frequent systemic rheumatic diseases associated with ILD are systemic sclerosis (SSc), rheumatoid arthritis (RA), and idiopathic inflammatory myositis. Treatment and monitoring guidelines are still lacking, and current treatment strategies have been extrapolated from the literature on SSc and established treatments for non-pulmonary systemic rheumatic manifestations. EXPERT OPINION Given the complexity of diagnosis and the paucity of treatment trials, managing CTD patients with ILD is challenging. It requires the skills of multidisciplinary CTD-ILD clinics including at least rheumatologists and lung specialists.
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Affiliation(s)
- Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy
| | - Alessandra Alciati
- Department of Clinical Neurosciences, Villa S. Benedetto Menni, Albese, Como, Italy
- Humanitas Clinical and Research Center, Rozzano, Italy
| | - Francesco Gozza
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy
| | | | - Cesare Siragusano
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy
| | - Nicolò Pipitone
- Rheumatology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Samad A, Wobma H, Casey A. Innovations in the care of childhood interstitial lung disease associated with connective tissue disease and immune-mediated disorders. Pediatr Pulmonol 2024; 59:2321-2337. [PMID: 38837875 DOI: 10.1002/ppul.27068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 04/05/2024] [Accepted: 05/07/2024] [Indexed: 06/07/2024]
Abstract
Childhood interstitial lung disease (chILD) associated with connective tissue and immune mediated disorders is the second most common chILD diagnostic category. As knowledge of the molecular and genetic underpinnings of these rare disorders advances, the recognized clinical spectrum of associated pulmonary manifestations continues to expand. Pulmonary complications of these diseases, including ILD, confer increased risk for morbidity and mortality and contribute to increased complexity for providers tasked with managing the multiple organ systems that can be impacted in these systemic disorders. While pulmonologists play an important role in diagnosis and management of these conditions, thankfully they do not have to work alone. In collaboration with a multidisciplinary team of subspecialists, the pulmonary and other systemic manifestations of these conditions can be managed effectively together. The goal of this review is to familiarize the reader with the classic patterns of chILD and other pulmonary complications associated with primary immune-mediated disorders (monogenic inborn errors of immunity) and acquired systemic autoimmune and autoinflammatory diseases. In addition, this review will highlight current, emerging, and innovative therapeutic strategies and will underscore the important role of multidisciplinary management to improving outcomes for these patients.
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Affiliation(s)
- Aaida Samad
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Holly Wobma
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alicia Casey
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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Potentas-Policewicz M, Fijolek J. Granulomatosis with polyangiitis: clinical characteristics and updates in diagnosis. Front Med (Lausanne) 2024; 11:1369233. [PMID: 39257888 PMCID: PMC11385631 DOI: 10.3389/fmed.2024.1369233] [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: 01/11/2024] [Accepted: 07/02/2024] [Indexed: 09/12/2024] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a rare systemic disease characterized by granulomatous inflammation of the respiratory tract and necrotizing vasculitis of small and medium vessels often associated with the production of anti-neutrophil cytoplasmic antibodies (ANCA) directed mainly against leukocyte proteinase 3 (PR3). Usually, it involves upper airways, lungs, and kidneys, however any organ may be affected. The diagnosis is based on clinical, radiological, and serological findings. Biopsies, although strongly recommended, are not always feasible and often provides non-specific features. ANCA plays a crucial role in the diagnosis of GPA; nevertheless, ANCA detection is not a substitute for biopsy, which plays an important role in suspected cases, particularly when histological confirmation cannot be obtained. Significant advances have been made in classification criteria and phenotyping of the disease, particularly in determining the nuances between PR3-ANCA and myeloperoxidase (MPO)-ANCA vasculitis. This has led to better characterization of patients and the development of targeted treatment in the future. In addition, better identification of cytokine and immunological profiles may result in immuno-phenotyping becoming a new approach to identify patients with ANCA-associated vasculitis (AAV). Due to the chronic relapsing-remitting nature, strict follow-up of GPA is necessary to provide appropriate management. The search for the accurate marker of disease activity and to predict relapse is still ongoing and no predictor has been found to reliably guide therapeutic decision-making.
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Affiliation(s)
| | - Justyna Fijolek
- The Third Department of Pneumonology and Oncology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
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7
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Shen HC, Bui KA, Richard R, Toban N, Lévesque M, Meunier R, Ross C, Makhzoum J. Comparison of Interstitial Lung Disease Between Antineutrophil Cytoplasmic Antibodies Positive and Negative Patients: A Retrospective Cohort Study. ACR Open Rheumatol 2024; 6:463-469. [PMID: 38733262 PMCID: PMC11319922 DOI: 10.1002/acr2.11679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 03/11/2024] [Accepted: 04/09/2024] [Indexed: 05/13/2024] Open
Abstract
OBJECTIVE Positive antineutrophil cytoplasmic antibodies (ANCAs) may occur in the setting of interstitial lung disease (ILD), with or without ANCA-associated vasculitis (AAV). We aim to compare the characteristics and clinical course of patients with ILD and positive ANCA (ANCA-ILD) to those with negative ANCA. METHODS We performed a single-center retrospective cohort study from 2018 to 2021. All patients with ILD and ANCA testing were included. Patient characteristics (symptoms, dyspnea scale, and systemic AAV), test results (pulmonary high-resolution computed tomography and pulmonary function tests), and adverse events were collected from electronic medical records. Descriptive statistics and the Fisher exact test were used to compare the outcomes of patients with ANCA-ILD to those with ILD and negative ANCA. RESULTS A total of 265 patients with ILD were included. The mean follow-up duration was 69.3 months, 26 patients (9.8%) were ANCA positive, and 69.2% of those with ANCA-ILD had another autoantibody. AAV occurred in 17 patients (65.4%) with ANCA-ILD. In 29.4% of patients, AAV developed following ILD diagnosis. Usual interstitial pneumonia was the most common radiologic pattern in patients with ANCA-ILD. There was no association between ANCA status and the evolution of dyspnea, diffusing capacity of the lungs for carbon monoxide, and lung imaging. Forced vital capacity improved over time in 42% of patients with ANCA-ILD and in 17% of patients with negative ANCA (P = 0.006). Hospitalization occurred in 46.2% of patients with ANCA-ILD and in 21.8% of patients with negative ANCA (P = 0.006). Both groups had similar mortality rates. CONCLUSION Routine ANCA testing should be considered in patients with ILD. Patients with ANCA-ILD are at risk for AAV. More research is required to better understand and manage patients with ANCA-ILD.
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Affiliation(s)
- Hao Cheng Shen
- Hôpital du Sacré‐Cœur de Montréal and Université de MontréalMontrealCanada
| | | | - Rachel Richard
- Hôpital du Sacré‐Cœur de Montréal and Université de MontréalMontrealCanada
| | - Nader Toban
- Hôpital du Sacré‐Cœur de Montréal and Université de MontréalMontrealCanada
| | - Marianne Lévesque
- Hôpital du Sacré‐Cœur de Montréal and Université de MontréalMontrealCanada
| | | | - Carolyn Ross
- Hôpital du Sacré‐Cœur de Montréal and Université de MontréalMontrealCanada
| | - Jean‐Paul Makhzoum
- Hôpital du Sacré‐Cœur de Montréal and Université de MontréalMontrealCanada
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8
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Salvati L, Palterer B, Lazzeri E, Vivarelli E, Amendola M, Allinovi M, Caroti L, Mazzoni A, Lasagni L, Emmi G, Cavigli E, Del Carria M, Di Pietro L, Scavone M, Cammelli D, Lavorini F, Tomassetti S, Rosi E, Parronchi P. Presentation and progression of MPO-ANCA interstitial lung disease. J Transl Autoimmun 2024; 8:100235. [PMID: 38445024 PMCID: PMC10912625 DOI: 10.1016/j.jtauto.2024.100235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/16/2024] [Accepted: 02/18/2024] [Indexed: 03/07/2024] Open
Abstract
The association between MPO-ANCA-associated vasculitis (AAV) and interstitial lung disease (ILD) has been well established. Pulmonary fibrosis may coexist with, follow, or even precede the diagnosis of AAV, and its presence adversely affects the prognosis. The optimal approach to investigating ANCA in patients with ILD remains a subject of ongoing debate. Here we aim to describe presentation and progression of MPO-ANCA ILD. We conducted a retrospective evaluation of a cohort of individuals diagnosed with MPO-ANCA ILD, with or without accompanying renal impairment, at the Immunology and Cell Therapy Unit, Careggi University Hospital, Florence, Italy, between June 2016 and June 2022. Clinical records, imaging studies, pathologic examinations, and laboratory test results were collected. Among the 14 patients identified with MPO-ANCA ILD, we observed a significant association between MPO-ANCA titers assessed at the time of ILD diagnosis and renal involvement. Renal impairment in these cases often manifested as subclinical or slowly progressive kidney damage. Interestingly, complement C3 deposits were consistently found in all renal biopsy specimens, thereby suggesting the potential for novel therapeutic targets in managing renal complications associated with MPO-ANCA ILD. The presentation of MPO-ANCA vasculitis as ILD can be the first and only clinical manifestation. MPO-ANCA levels at ILD diagnosis could warn on the progression to renal involvement in patients with MPO-ANCA ILD, hence caution is needed because renal disease can be subclinical or smoldering.
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Affiliation(s)
- Lorenzo Salvati
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Boaz Palterer
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Elena Lazzeri
- Department of Clinical and Experimental Biomedical Sciences, Excellence Centre for Research, Transfer and High Education for the Development of DE NOVO Therapies (DENOTHE), University of Florence, Florence, Italy
| | - Emanuele Vivarelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marina Amendola
- Pneumology and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Marco Allinovi
- Nephrology Unit, Careggi University Hospital, Florence, Italy
| | - Leonardo Caroti
- Nephrology Unit, Careggi University Hospital, Florence, Italy
| | - Alessio Mazzoni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Flow Cytometry Diagnostic Center and Immunotherapy, Careggi University Hospital, Florence, Italy
| | - Laura Lasagni
- Department of Clinical and Experimental Biomedical Sciences, Excellence Centre for Research, Transfer and High Education for the Development of DE NOVO Therapies (DENOTHE), University of Florence, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Edoardo Cavigli
- Department of Emergency Radiology, Careggi University Hospital, Florence, Italy
| | - Marco Del Carria
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Linda Di Pietro
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Mariangela Scavone
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Daniele Cammelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Pneumology and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Sara Tomassetti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Interventional Pulmonology Unit, Careggi University Hospital, Florence, Italy
| | - Elisabetta Rosi
- Pneumology and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Paola Parronchi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Immunology and Cell Therapy Unit, Careggi University Hospital, Florence, Italy
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Zonozi R, Cortazar FB, Jeyabalan A, Sauvage G, Nithagon P, Huizenga NR, Rosenthal JM, Sipilief A, Cosgrove K, Laliberte KA, Rhee EP, Pendergraft WF, Niles JL. Maintenance of remission of ANCA vasculitis by rituximab based on B cell repopulation versus serological flare: a randomised trial. Ann Rheum Dis 2024; 83:351-359. [PMID: 38123922 DOI: 10.1136/ard-2023-224489] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/23/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To compare two long-term remission maintenance strategies for antineutrophil cytoplasmic antibody (ANCA) vasculitis. METHODS We conducted a prospective, single-centre, open-label, randomised controlled trial of patients with ANCA vasculitis in remission after completing at least 2 years of fixed-schedule rituximab. In the B cell arm, rituximab was reinfused upon B cell repopulation; in the ANCA arm, rituximab was reinfused upon significant rise in ANCA level. Evaluations were conducted every 3 months. The primary endpoint was clinical relapse, defined as a modified BVAS/WG >0 by 36 months. Secondary endpoints included serious adverse events (SAEs) and rituximab exposure. RESULTS 115 patients were enrolled. Median follow-up time was 4.1 years (IQR 2.5-5.0). By Kaplan-Meier analysis, 4.1% (95% CI 1.0 to 15.6) of patients had a clinical relapse in the B cell arm, compared with 20.5% (95% CI 11.9 to 34.1) in the ANCA arm, at 3 years after study entry (log-rank p=0.045). Total SAEs, including infectious SAEs, and deaths did not differ. The number of SAEs due to COVID-19 was higher in the B cell arm (p=0.049). In the B cell arm, patients received a mean of 3.6 (SD 2.4) infusions (3.6 g) per person over the median study follow-up time of 4.1 years, compared with 0.5 (SD 1.4) infusions (0.5 g) per patient in the ANCA arm (p<0.001). CONCLUSIONS Rituximab dosed for B cell repopulation results in fewer clinical relapses than when dosed for a rise in ANCA level in maintenance of remission for ANCA vasculitis. Overall safety was equivalent; SAEs due to COVID-19 and rituximab exposure were higher with the B cell strategy. TRIAL REGISTRATION NUMBER NCT02749292.
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Affiliation(s)
- Reza Zonozi
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Frank B Cortazar
- New York Nephrology Vasculitis and Glomerular Center, Albany, New York, USA
| | - Anushya Jeyabalan
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriel Sauvage
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pravarut Nithagon
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Noah R Huizenga
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jillian M Rosenthal
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alexander Sipilief
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Katherine Cosgrove
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen A Laliberte
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eugene P Rhee
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - John L Niles
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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10
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Saha MK. Overview of Vasculitides in Adults. Neuroimaging Clin N Am 2024; 34:1-12. [PMID: 37951696 DOI: 10.1016/j.nic.2023.07.007] [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] [Indexed: 11/14/2023]
Abstract
Vasculitis is characterized by the inflammation of blood vessels. Vasculitides refers to the different forms of vasculitis, often classified according to the size of the blood vessel that is involved. Vasculitis may occur as a primary process or secondary to many systemic diseases. This topic provides an overview of the clinical features, diagnosis, and classification of the different forms of vasculitides.
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Affiliation(s)
- Manish K Saha
- Division of Nephrology, University of North Carolina, Chapel Hill, NC, USA.
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11
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Zhang Y, Ding Q, Lv C, Ying Y, Cen Z, Zhou H, Wu T. Clinical significance of microscopic polyangiitis with interstitial lung disease and bronchiectasis: probability of preexisting comorbidities. Ann Med 2023; 55:2204449. [PMID: 37126372 PMCID: PMC10134949 DOI: 10.1080/07853890.2023.2204449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND The association between pulmonary involvement and microscopic polyangiitis (MPA) has been increasingly recognized in recent years. Whether interstitial lung disease (ILD) and bronchiectasis (BE) are disease manifestations of MPA, preexisting comorbidities or important complications remains unclear. The purpose of this study was to determine the clinical characteristics and prognosis of MPA with pulmonary involvement to further guide clinical management. METHODS The data for 97 patients with a definitive diagnosis of MPA were retrospectively reviewed. The MPA diagnosis was based on the 2012 revised Chapel Hill Consensus Conference (CHCC) criteria. The baseline clinical information and laboratory parameters were collected and analysed at each patient's initial diagnosis. RESULTS Forty-seven out of the 97 (48.5%) patients who were diagnosed with MPA presented with pulmonary involvement, including 37 patients with ILD, 12 patients with BE and two patients with diffuse alveolar haemorrhage (DAH). ILD and BE antedated MPA in 56.76% and 75.00% of the patients, respectively. Compared with that in the MPA-BE group, the serum LDH level (222.86 ± 68.19 vs. 171.58 ± 31.43, p = .016) in the MPA-ILD group was significantly higher. In the multivariate Cox analysis, elevated serum creatinine (HR 4.08, confidence interval (CI) 1.38-12.05, p = .011) was an independent risk factor for shorter survival in MPA patients with pulmonary involvement, and treatment with glucocorticoid pulse cyclophosphamide therapy (HR 0.095, 95% CI 0.019-0.47, p = .004) was independently associated with prolonged survival. Among the patients in the MPA-ILD group, acute exacerbations of ILD (HR 4.55 CI 1.16-17.86, p = .029) and elevated serum creatinine (HR 4.95, CI 1.39-17.54, p = .014) were independently associated with a poor prognosis, and treatment with glucocorticoids (HR 0.057, 95% CI 0.012-0.28, p < .001) was independently associated with significant prolongation of survival. CONCLUSIONS Patients with MPA have a high prevalence of pulmonary involvement, and ILD is the most common subtype of MPA. ILD and BE can be considered preexisting comorbidities of MPA. Elevated serum creatinine was associated with shorter survival. However, remission induction regimens with glucocorticoids and/or immunosuppressants may improve this outcome.
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Affiliation(s)
- Yun Zhang
- Department of Respiratory, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Qunli Ding
- Department of Respiratory, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Chengna Lv
- Department of Respiratory, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Yanan Ying
- Department of Respiratory, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Zekai Cen
- Department of Respiratory, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Haijun Zhou
- Department of Rheumatology, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Tingting Wu
- Department of Respiratory, The First Affiliated Hospital of Ningbo University, Ningbo, China
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12
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Mor E, Balbir-Gurman A, Guralnik L, Naroditski I, Zayoud M, Dotan Y. An unexpected diagnosis of a 57-year-old women with migratory pulmonary infiltrates. Respir Med Case Rep 2023; 44:101873. [PMID: 37234721 PMCID: PMC10205530 DOI: 10.1016/j.rmcr.2023.101873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
A 57-year-old female presented with sudden shortness of breath and migratory pulmonary infiltrates on imaging, which corresponds with a diagnosis of cryptogenic organizing pneumonia. Initial treatment with corticosteroids showed only mild improvement during follow-up. BAL was performed and revealed diffuse alveolar hemorrhage. Immune testing showed positive P-ANCA with positive MPO, leading to a diagnosis of microscopic polyangiitis.
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Affiliation(s)
- Elad Mor
- Division of Pulmonary Medicine Rambam Health Care Campus, Israel
| | - Alexandra Balbir-Gurman
- B. Shine Rheumatology Unit Rambam Health Care Campus, Israel
- Faculty of Medicine, Technion-Israel Institute of Technology, Israel
| | - Ludmila Guralnik
- Department of Medical Imaging Rambam Health Care Campus, Israel
- Faculty of Medicine, Technion-Israel Institute of Technology, Israel
| | - Inna Naroditski
- Pathology Institue Rambam Health Care Campus, Israel
- Faculty of Medicine, Technion-Israel Institute of Technology, Israel
| | - Morad Zayoud
- Pathology Institue Rambam Health Care Campus, Israel
| | - Yaniv Dotan
- Division of Pulmonary Medicine Rambam Health Care Campus, Israel
- Faculty of Medicine, Technion-Israel Institute of Technology, Israel
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13
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Bozzao F, Tomietto P, Baratella E, Kodric M, Cifaldi R, Della Porta R, Prearo I, Pirronello SMG, Confalonieri P, Ruaro B, Fischetti F, Fabris B. Clinical Characterization and Predictive Factors for Progression in a Cohort of Patients with Interstitial Lung Disease and Features of Autoimmunity: The Need for a Revision of IPAF Classification Criteria. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:794. [PMID: 37109752 PMCID: PMC10146211 DOI: 10.3390/medicina59040794] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/03/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: The "interstitial pneumonia with autoimmune features" (IPAF) criteria have been criticized because of the exclusion of usual interstitial pneumonia (UIP) patients with a single clinical or serological feature. To classify these patients, the term UIPAF was proposed. This study aims to describe clinical characteristics and predictive factors for progression of a cohort of interstitial lung disease (ILD) patients with at least one feature of autoimmunity, applying criteria for IPAF, specific connective tissue diseases (CTD), and a definition of UIPAF when possible. Methods: We retrospectively evaluated data on 133 consecutive patients with ILD at onset associated with at least one feature of autoimmunity, referred by pulmonologists to rheumatologists from March 2009 to March 2020. Patients received 33 (16.5-69.5) months of follow-up. Results: Among the 101 ILD patients included, 37 were diagnosed with IPAF, 53 with ILD-onset CTD, and 11 with UIPAF. IPAF patients had a lower prevalence of UIP pattern compared to CTD-ILD and UIPAF patients (10.8% vs. 32.1% vs. 100%, p < 0.01). During the follow-up, 4 IPAF (10.8%) and 2 UIPAF (18.2%) patients evolved into CTD-ILD. IPAF patients presented features not included in IPAF criteria, such as sicca syndrome (8.1%), and were more frequently affected by systemic hypertension (p < 0.01). Over one year, ILD progression (greater extent of fibrosis on HRCT and/or decline in PFTs) was less frequent in the IPAF group compared to CTD-ILD and UIPAF (32.3% vs. 58.8% vs. 72.7, p = 0.02). A UIP pattern and an IPAF predicted a faster (OR: 3.80, p = 0.01) and a slower (OR: 0.28, p = 0.02) ILD progression, respectively. Conclusions: IPAF criteria help identify patients who might develop a CTD-ILD, even though a single clinical or serological feature is respected. Future revisions of IPAF criteria should include sicca syndrome and separate UIP-pattern into a different definition (UIPAF), given its association with a different prognosis, independently from ILD classification.
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Affiliation(s)
- Francesco Bozzao
- Internal Medicine Department, Azienda ULSS 2 “Marca Trevigiana”, 31100 Treviso, Italy
| | - Paola Tomietto
- Internal Medicine Department, Rheumatology Unit, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), 34128 Trieste, Italy
| | - Elisa Baratella
- Institute of Radiology, Department of Medical Surgical and Health Sciences, Cattinara Hospital, University of Trieste, 34128 Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34128 Trieste, Italy
| | - Metka Kodric
- Pneumology Unit, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), 34128 Trieste, Italy
| | - Rossella Cifaldi
- Pneumology Unit, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), 34128 Trieste, Italy
| | - Rossana Della Porta
- Pneumology Unit, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), 34128 Trieste, Italy
| | - Ilaria Prearo
- Vascular Medicine Unit, University Hospital LMU Munich, 81377 Munich, Germany
| | | | - Paola Confalonieri
- Pneumology Unit, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), 34128 Trieste, Italy
| | - Barbara Ruaro
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34128 Trieste, Italy
- Pneumology Unit, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), 34128 Trieste, Italy
| | - Fabio Fischetti
- Internal Medicine Department, Rheumatology Unit, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), 34128 Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34128 Trieste, Italy
| | - Bruno Fabris
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34128 Trieste, Italy
- Internal Medicine Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), 34128 Trieste, Italy
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Hill ML, Moua T. 73-Year-Old Man With Dyspnea and Cough. Mayo Clin Proc 2023; 98:789-794. [PMID: 37028978 DOI: 10.1016/j.mayocp.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 04/09/2023]
Affiliation(s)
- Meghan L Hill
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Teng Moua
- Advisor to resident and Consultant in Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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15
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Ouchene L, Muntyanu A, Assayag D, Veilleux È, Abril A, Ferrara G, Yacyshyn E, Pineau CA, O'Brien E, Baron M, Osman M, Gniadecki R, Netchiporouk E. Skin disorders and interstitial lung disease: Part II-The spectrum of cutaneous diseases with lung disease association. J Am Acad Dermatol 2023; 88:767-782. [PMID: 36228940 DOI: 10.1016/j.jaad.2022.09.051] [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: 06/30/2022] [Revised: 08/30/2022] [Accepted: 09/07/2022] [Indexed: 11/06/2022]
Abstract
Part 2 of this 2-part CME introduces dermatologists to noninfectious inflammatory skin diseases associated with pulmonary involvement. In many cases, dermatologists may be the first physicians recognizing respiratory complications associated with these diagnoses. Because pulmonary involvement is often the leading cause of morbidity and mortality, dermatologists should be comfortable screening and monitoring for lung disease in high-risk patients, recognizing cutaneous stigmata of lung disease in these patients and referring to pulmonary specialists, when appropriate, for prompt treatment initiation. Some treatments used for skin disease may not be appropriate in the context of lung disease and hence, choosing a holistic approach is important. Interstitial lung disease and pulmonary hypertension are the most common pulmonary complications and a significant cause of mortality in autoimmune connective tissue diseases, especially systemic sclerosis, dermatomyositis, and mixed connective tissue disease. Pulmonary complications, notably interstitial lung disease, are also common and life-threatening in sarcoidosis and vasculitis, while they are variable in neutrophilic and autoimmune blistering diseases.
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Affiliation(s)
- Lydia Ouchene
- Division of Dermatology, McGill University Health Centre, Montréal, Québec, Canada
| | - Anastasiya Muntyanu
- Division of Dermatology, McGill University Health Centre, Montréal, Québec, Canada
| | - Deborah Assayag
- Division of Pulmonary Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Èvicka Veilleux
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Andy Abril
- Division of Rheumatology, Mayo Clinic, Jacksonville, Florida
| | - Giovanni Ferrara
- Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Elaine Yacyshyn
- Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
| | - Christian A Pineau
- Division of Rheumatology, McGill University Health Centre, Montréal, Québec, Canada
| | - Elizabeth O'Brien
- Division of Dermatology, McGill University Health Centre, Montréal, Québec, Canada
| | - Murray Baron
- Division of Rheumatology, McGill University Health Centre, Montréal, Québec, Canada
| | - Mohammed Osman
- Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Gniadecki
- Division of Dermatology, University of Alberta, Edmonton, Alberta, Canada
| | - Elena Netchiporouk
- Division of Dermatology, McGill University Health Centre, Montréal, Québec, Canada.
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16
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Paroli M, Gioia C, Accapezzato D. New Insights into Pathogenesis and Treatment of ANCA-Associated Vasculitis: Autoantibodies and Beyond. Antibodies (Basel) 2023; 12:antib12010025. [PMID: 36975372 PMCID: PMC10045085 DOI: 10.3390/antib12010025] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/29/2023] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a group of rare systemic diseases affecting small-caliber vessels. The damage caused by AAV mainly involves the lung and kidneys. AAV includes three different types: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Although the different phenotypic forms of AAV share common features, recent studies have shown that there are significant differences in terms of pathogenetic mechanisms involving both the adaptive and innate immune systems. Advances in our understanding of pathogenesis have enabled the development of immuno-targeted therapies. This review illustrates the characteristics of the various forms of AAV and the new therapies available for this disease that can have lethal consequences if left untreated.
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Affiliation(s)
- Marino Paroli
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Chiara Gioia
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Daniele Accapezzato
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
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17
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Interstitial Lung Disease and Anti-Neutrophil Cytoplasmic Antibody–Associated Vasculitis. Immunol Allergy Clin North Am 2023; 43:379-388. [PMID: 37055094 DOI: 10.1016/j.iac.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Interstitial lung disease is a common complication of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV). It is seen most commonly in microscopic polyangiitis owing to the pathogenic effect of myeloperoxidase in the lung. Oxidative stress, neutrophil elastase release, and expression of inflammatory proteins by neutrophil extracellular traps result in fibroblast proliferation and differentiation and therefore fibrosis. Usually, interstitial pneumonia pattern fibrosis is common and associated with poor survival. Treatment for patients with AAV and interstitial lung disease lacks evidence, and those with vasculitis are treated with immunosuppression, whereas those with progressive fibrosis may well benefit from antifibrotic therapy.
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18
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Doliner B, Rodriguez K, Montesi SB, Fu X, Sharma A, Wallace ZS. Interstitial lung disease in ANCA-associated vasculitis: associated factors, radiographic features and mortality. Rheumatology (Oxford) 2023; 62:716-725. [PMID: 35699465 PMCID: PMC9891428 DOI: 10.1093/rheumatology/keac339] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/19/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To evaluate the prevalence, clinical and radiographic features, and long-term outcomes of interstitial lung disease (ILD) in a United States-based ANCA-associated vasculitis (AAV) cohort. METHODS In this retrospective cohort study, we identified cases of ILD within the 2002-2019 Mass General Brigham AAV Cohort, a consecutive inception cohort of PR3- or MPO-ANCA+ AAV patients. ILD diagnosis and classification as fibrotic or non-fibrotic were confirmed by review of available chest imaging by two board-certified radiologists. Cox proportional hazard models, with age as the time scale, were used to estimate the association of AAV-ILD with all-cause mortality. RESULTS Of 684 patients in the MGB AAV Cohort, 91 (13%) had ILD which preceded the diagnosis of AAV by a mean of 2.2 years. AAV-ILD patients were older (67 vs 60 years, P < 0.001) than patients without ILD but the distribution of sex and race was similar. AAV-ILD patients were more often MPO-ANCA+ (93% vs 65%, P < 0.001); among MPO-ANCA+ patients (n = 470), 85 (18%) had ILD. The majority of ILD was fibrotic (76%) and UIP was the most common ILD pattern (42%). The baseline forced vital capacity (FVC) % predicted among ILD patients was 81 ± 20%. Fibrotic AAV-ILD was associated with a 58% higher risk of death (aHR 1.58, 95% CI 1.06, 2.37) compared with AAV patients without ILD. CONCLUSION ILD is a frequent complication of AAV, especially MPO-ANCA+ AAV, often preceding recognition of AAV. Fibrotic AAV-ILD is associated with a higher risk of death than AAV without ILD.
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Affiliation(s)
- Brett Doliner
- Department of Medicine, Massachusetts General Hospital.,Harvard Medical School
| | | | - Sydney B Montesi
- Harvard Medical School.,Division of Pulmonary and Critical Care Medicine
| | - Xiaoqing Fu
- Clinical Epidemiology Program, Mongan Institute.,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Zachary S Wallace
- Harvard Medical School.,Clinical Epidemiology Program, Mongan Institute.,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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19
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Wang Y, Qu Z, Liang W, Chen X, Chen C, Cheng H, Hu H, Wei Z, Su K, Yang L, Wang H. Clinical features and markers to identify pulmonary lesions caused by infection or vasculitis in AAV patients. BMC Pulm Med 2023; 23:27. [PMID: 36653805 PMCID: PMC9850570 DOI: 10.1186/s12890-023-02317-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Pulmonary lesion is frequently seen in ANCA-associated vasculitis (AAV) patients primarily due to AAV lung involvement or infection, which are hard to differentiate due to their high similarity in clinical manifestations. We aimed to analyze the clinical features of pulmonary lesions consequent to AAV involvement or infection in AAV patients and further identify the markers for differential diagnosis. METHODS 140 AAV patients who admitted to the Renmin Hospital of Wuhan University from January 2016 to July 2021 were included in this study. According to the nature of lung conditions, these patients were divided into the non-pulmonary lesion group, the lung infection group and the non-pulmonary infection group, and their demographics, clinical symptoms, imaging features, as well as laboratory findings were compared. A receiver operating characteristic (ROC) curve was drawn, and the diagnostic efficacy of single biomarker and composite biomarkers on pulmonary infection was then evaluated. RESULTS The patients in the lung infection group were significantly older than those in the no lesion group (63.19 ± 14.55 vs 54.82 ± 15.08, p = 0.022). Patients in the lung infection group presented more frequent symptoms and more obvious pulmonary image findings. Compared with patients in the non-pulmonary infection group, patients in the lung infection group showed a higher symptom incidence of fever, chest tightness, cough and expectoration, and hemoptysis (52.94% vs 16.00%, 61.76% vs 40.00%, 72.06% vs 46.00%, 27.94% vs 8.00%, p < 0.05, respectively), and more changes in pulmonary CT scanning images in terms of patched/striped compact opacity, alveolar hemorrhage, bronchiectasis, pleural effusion, as well as mediastinal lymphadenopathy (89.71% vs 52.00%, 11.76% vs 2.00%, 22.06% vs 8.00%, 50.00% vs 20.00%, 48.53% vs 24.00%, p < 0.05, respectively). In addition, patients in the lung infection group had significantly higher levels of serum pro-calcitonin (PCT), C-reactive protein (CRP), amyloid A (SAA), blood neutrophil-to-lymphocyte ratio (NLCR), erythrocyte sedimentation rate (ESR), as well as Birmingham vasculitis activity score (BVAS) than patients in the other two groups (p < 0.05). Among all biomarkers, PCT exhibited the highest diagnostic efficacy (0.928; 95%CI 0.89-0.97) for pulmonary infected AAV patients at a cut-off score of 0.235 ng/ml with 85.3% sensitivity and 84% specificity. Moreover, the composite biomarker of PCT-CRP-NLCR showed more diagnostic efficacy (0.979; 95% CI 0.95-1.00) in distinguishing the infectious and non-infectious lung injuries in AAV patients. CONCLUSIONS AAV patients with lung infection manifested more clinical symptoms and prominent lung image changes. The PCT and composite biomarker PCT-CRP-NLCR showed high diagnostic efficacy for a lung infection in AAV patients. Pulmonary lesion caused by either infection or AAV involvement is commonly seen and difficult to distinguish. We aim to identify the biomarkers that can be applied in the differentiation diagnosis of pulmonary lesions in AAV patients.
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Affiliation(s)
- Yujuan Wang
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Zhuan Qu
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Wei Liang
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Xinghua Chen
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Cheng Chen
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Hui Cheng
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Haiyun Hu
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Zhongpin Wei
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Ke Su
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Lianhua Yang
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Huiming Wang
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
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20
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Wu T, Zhang Y, Cen Z, Ying Y, Sun C, Lv C, Ding Q. Clinical significance of acute exacerbation in interstitial lung disease with antineutrophil cytoplasmic antibody: an indicator of poor prognosis. Ther Adv Respir Dis 2022; 16:17534666221140974. [PMID: 36484348 PMCID: PMC9742717 DOI: 10.1177/17534666221140974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The association between interstitial lung disease (ILD) and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) has been increasingly recognized in recent years. The clinical features and prognostic differences between AAV-associated ILD and isolated ANCA-positive idiopathic interstitial pneumonias (IIPs) remain unclear. The purpose of this study was to determine the clinical significance and prognosis of ANCA-positive ILD to further guide clinical management. METHODS This study retrospectively reviewed the data of 379 ILD patients with available ANCA results and ultimately analysed 49 ANCA-positive patients. AAV diagnosis was based on the 2012 revised Chapel Hill Consensus Conference (CHCC) criteria, and 33 of 49 patients were diagnosed with microscopic polyangiitis (MPA). The baseline clinical information and laboratory parameters were collected and analysed at each patient's initial diagnosis. RESULTS Among 49 ANCA-positive ILD patients, the high-resolution computed tomography (HRCT) pattern was mainly usual interstitial pneumonia (UIP) (59.18%), followed by nonspecific interstitial pneumonia (NSIP) (26.53%). The C-reactive protein (CRP) level (43.89± 40.61 versus 18.74± 20.05, p = 0.028) and erythrocyte sedimentation rate (ESR) (71.97± 42.73 versus 40.69± 28.46, p = 0.011) were significantly higher in the MPA-ILD group than in the ANCA-IIP group. Haemoglobin (113.09 ± 24.47 versus 132.19± 13.34, p = 0.006) and albumin (32.95± 5.84 versus 36.52± 3.94, p = 0.032) levels were significantly lower. Survival was shorter among MPA-ILD patients than among ANCA-IIP patients [hazard ratio (HR) 3.38, 95% confidence interval (CI) 1.32-8.67, p = 0.040]. In the multivariable Cox analysis, a diagnosis of MPA (HR 3.91, 95% CI 1.07-14.08, p = 0.038) and acute exacerbation (AE) of ILD (HR 9.43, 95% CI 2.89-30.30, p < 0.001) were significantly independently associated with shorter survival in ANCA-positive ILD patients, and the NSIP pattern (HR 0.07, 95% CI 0.01-0.41, p = 0.003) was independently associated with prolonged survival. CONCLUSION ANCA-ILD patients mostly have myeloperoxidase (MPO)-ANCA positivity and an MPA diagnosis. Survival was shorter among MPA-ILD patients than among ANCA-IIP patients. Respiratory failure and AE were associated with poorer prognosis. Early antifibrotic treatment may be a reasonable treatment option in fibrotic ILD patients with ANCA positivity.
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Affiliation(s)
- Tingting Wu
- Department of Respiratory, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, China
| | - Yun Zhang
- Department of Respiratory, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, China
| | - Zekai Cen
- Department of Respiratory, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, China
| | - Yanan Ying
- Department of Respiratory, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, China
| | - Chao Sun
- Department of Respiratory, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, China
| | - Chengna Lv
- Department of Respiratory, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, China
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Hernández Muñiz S, Olivera Serrano M, Jiménez Heffernan J, Valenzuela C, Caballero Sánchez-Robles P. Enfermedad intersticial asociada a conectivopatías y vasculitis. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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22
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Hernández Muñiz S, Olivera Serrano MJ, Jiménez Heffernan JA, Valenzuela C, Caballero Sánchez-Robles P. Interstitial disease associated with connective tissue disease and vasculitis. RADIOLOGIA 2022; 64 Suppl 3:250-264. [PMID: 36737164 DOI: 10.1016/j.rxeng.2022.07.004] [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: 05/30/2022] [Accepted: 07/22/2022] [Indexed: 02/05/2023]
Abstract
Systemic autoimmune diseases comprise a complex, heterogeneous group of entities. Noteworthy among the pulmonary complications of these entities is interstitial involvement, which manifests with the same radiopathologic patterns as in idiopathic interstitial pneumonia. High-resolution computed tomography is the gold-standard imaging technique; it enables us to identify and classify the disease and to determine its extent, providing useful information about the prognosis. In this group of processes, the most common pattern of presentation is nonspecific interstitial pneumonia. It is essential for radiologists to work together in collaboration with other specialists to reach the correct diagnosis and enable appropriate, integrated treatment.
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Affiliation(s)
- S Hernández Muñiz
- Servicio de Radiodiagnóstico, Hospital Universitario de La Princesa, Madrid, Spain; Universidad Autónoma de Madrid, Madrid, Spain; Cátedra UAM-Roche EPID-futuro (Universidad Autónoma de Madrid), Madrid, Spain.
| | - M J Olivera Serrano
- Servicio de Radiodiagnóstico, Hospital Universitario de La Princesa, Madrid, Spain; Universidad Autónoma de Madrid, Madrid, Spain
| | - J A Jiménez Heffernan
- Universidad Autónoma de Madrid, Madrid, Spain; Servicio de Anatomía Patológica, Hospital Universitario de La Princesa, Madrid, Spain
| | - C Valenzuela
- Universidad Autónoma de Madrid, Madrid, Spain; Cátedra UAM-Roche EPID-futuro (Universidad Autónoma de Madrid), Madrid, Spain; Servicio de Neumología, Hospital Universitario de La Princesa, Madrid, Spain
| | - P Caballero Sánchez-Robles
- Servicio de Radiodiagnóstico, Hospital Universitario de La Princesa, Madrid, Spain; Universidad Autónoma de Madrid, Madrid, Spain
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23
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Luo L, Li H, Tang J, Liao Z, Wang F, Jin Y, Zhou F, Feng J, Li X. Clinical characteristics and outcomes of MPO-ANCA-associated glomerulonephritis with bronchiectasis: A retrospective case-control study. Semin Arthritis Rheum 2022; 57:152082. [DOI: 10.1016/j.semarthrit.2022.152082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/27/2022] [Accepted: 08/10/2022] [Indexed: 10/15/2022]
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24
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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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25
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Bell PT, Sheehy R, Droney L, Prain K, Wong R, Keir GJ. Pulmonary involvement in Anti-Neutrophil Cytoplasmic Antibody Associated Vasculitis: A single centre case series. Respirol Case Rep 2022; 10:e01058. [PMID: 36284753 PMCID: PMC9585386 DOI: 10.1002/rcr2.1058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 10/09/2022] [Indexed: 11/07/2022] Open
Abstract
Anti-Neutrophil Cytoplasmic Antibody associated Vasculitides (AAV) comprise a rare group of disorders in which respiratory tract involvement is variable and often severe. The rarity and heterogeneity of AAV makes this a challenging condition to diagnose and manage. In this single-centre case series of 44 patients with AAV-associated respiratory disease, we provide an overview of disease manifestations, management aspects and treatment outcomes. Data from this case series highlight the real-world diagnostic and therapeutic challenges of the AAV respiratory disease spectrum; including uncertainties in the management of fibrosing interstitial lung disease, tracheobronchial stenosis and diffuse alveolar haemorrhage.
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Affiliation(s)
- Peter T. Bell
- Department of Respiratory and Sleep MedicinePrincess Alexandra HospitalBrisbaneQueenslandAustralia
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia
| | - Robert Sheehy
- Department of Respiratory and Sleep MedicinePrincess Alexandra HospitalBrisbaneQueenslandAustralia
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia
| | - Luke Droney
- Department of ImmunologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
- Division of ImmunologyPathology QueenslandBrisbaneQueenslandAustralia
| | - Kerri Prain
- Division of ImmunologyPathology QueenslandBrisbaneQueenslandAustralia
| | - Richard Wong
- Department of ImmunologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
- Division of ImmunologyPathology QueenslandBrisbaneQueenslandAustralia
| | - Gregory J. Keir
- Department of Respiratory and Sleep MedicinePrincess Alexandra HospitalBrisbaneQueenslandAustralia
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia
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26
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Folci M, Ramponi G, Solitano V, Brunetta E. Serum ANCA as Disease Biomarkers: Clinical Implications Beyond Vasculitis. Clin Rev Allergy Immunol 2022; 63:107-123. [PMID: 34460071 DOI: 10.1007/s12016-021-08887-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 01/13/2023]
Abstract
Usually associated with autoimmune diseases, anti-neutrophil cytoplasmic antibodies are also detected in other conditions, such as infections, malignancies, and after intake of certain drugs. Even if the mechanisms of production and their pathogenic role have not been fully elucidated yet, ANCA are widely recognized as a clinically alarming finding due to their association with various disorders. While ANCA target several autoantigens, proteinase-3, and myeloperoxidase are the ones proved to be most frequently related to chronic inflammation and tissue damage in murine models. Albeit these autoantibodies could be present as an isolated observation without any implications, ANCA are frequently used in clinical practice to guide the diagnosis in a suspect of small vessel vasculitis. Conditions that should prompt the clinician to test ANCA status range from various forms of lung disease to renal or peripheral nervous system impairment. ANCA positivity in the presence of an autoimmune disease, especially rheumatoid arthritis, or connective tissue diseases, is frequently correlated with more clinical complications and treatment inefficacy, even in the absence of signs of vasculitis. For this reason, it has been postulated that ANCA could represent the final expression of an immune dysregulation rather than a pathogenic event responsible for organs damage. Recently, it has also been proposed that ANCA specificity (PR3 or MPO) could possibly define ANCA-associated vasculitides better than clinical phenotype. This review aims at summarizing the latest advancements in the field of ANCA study and clinical interpretation.
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Affiliation(s)
- Marco Folci
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.
| | | | - Virginia Solitano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Enrico Brunetta
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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27
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Trivioli G, Marquez A, Martorana D, Tesi M, Kronbichler A, Lyons PA, Vaglio A. Genetics of ANCA-associated vasculitis: role in pathogenesis, classification and management. Nat Rev Rheumatol 2022; 18:559-574. [PMID: 36109667 DOI: 10.1038/s41584-022-00819-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2022] [Indexed: 12/15/2022]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) comprises granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA), that share features of pauci-immune small-vessel vasculitis and the positivity of ANCA targeting proteinase-3 (PR3-ANCA) or myeloperoxidase (MPO-ANCA). AAV syndromes are rare, complex diseases and their aetio-pathogenesis is mainly driven by the interaction between environmental and genetic factors. In patients with GPA and MPA, the genetic associations are stronger with ANCA specificity (PR3- versus MPO-ANCA) than with the clinical diagnosis, which, in keeping with the known clinical and prognostic differences between PR3-ANCA-positive and MPO-ANCA-positive patients, supports an ANCA-based re-classification of these disorders. EGPA is also made up of genetically distinct subsets, which can be stratified on ANCA-status (MPO ANCA-positive versus ANCA-negative); these subsets differ in clinical phenotype and possibly in their response to treatment. Interestingly, MPO-ANCA-positive patients with either MPA or EGPA have overlapping genetic determinants, thus strengthening the concept that this EGPA subset is closely related to the other AAV syndromes. The genetics of AAV provides us with essential information to understand its varied phenotype. This Review discusses the main findings of genetic association studies in AAV, their pathogenic implications and their potential effect on classification, management and prognosis.
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Affiliation(s)
- Giorgio Trivioli
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Ana Marquez
- Institute of Parasitology and Biomedicine "López-Neyra", CSIC, Granada, Spain
| | - Davide Martorana
- Medical Genetics Unit, Department of Diagnostics, University Hospital of Parma, Parma, Italy
- CoreLab Unit, Research Center, University Hospital of Parma, Parma, Italy
| | - Michelangelo Tesi
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Vasculitis and Lupus Service, Department of Renal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, UK
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy.
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy.
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28
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Zhu Q, Li F, Xie X, Chen B, Yu Q, Wei Y, Ge Y. Relationship Between Gender and 1-Year Mortality in ANCA-Associated Vasculitis Patients: A Single-Center Retrospective Analysis and Meta-Analysis. Front Med (Lausanne) 2022; 9:945011. [PMID: 35911416 PMCID: PMC9326069 DOI: 10.3389/fmed.2022.945011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The relationship between gender and short-term prognosis of patients with anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) is unclear, hence single-center retrospective analysis and meta-analysis were conducted to determine the relationship. Methods Initially treated patients with AAV were retrospectively enrolled. Data of clinical manifestation, laboratory indicators, Birmingham vasculitis activity score (BVAS), therapeutic treatments, and the patients' situations within 1 year were recorded. First, we compared the basic characteristics between male and female patients. Second, the risk factors associated with a 1-year mortality rate of patients with AAV were evaluated. Finally, a meta-analysis was performed to explore the effect of gender on 1-year mortality in patients with AAV. Results The study involved 84 patients with AAV, including 33 female and 51 male participants. In total, 14 people died (12 males and 2 females) and 70 survived in the 1st year. Statistical differences were noted in the age of onset, the course of the disease, WBC, HB, N, ESR, CRP, BUN, ALT and ALB, BVAS, and 1-year mortality rate between male and female participants. In male patients, elevated Scr, NLR, PLT, and RDW-CV were associated with poor AAV (P < 0.05) prognosis. The meta-analysis verified that male gender was an independent risk factor for the 1-year mortality of patients with AAV(OR = 1.54). Conclusion Significant sex-specific differences were found in patients with AAV. Male patients contributed to 1.54-fold of 1-year mortality risk in patients with AAV by meta-analysis. More attention should be paid to the mortality risk of male patients with AAV in the early stage.
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Affiliation(s)
- Qing Zhu
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Rheumatology and Immunology, Jingzhou Hospital, Yangtze University, Jingzhou, China
| | - Fen Li
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xi Xie
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Bilin Chen
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qianwen Yu
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yusong Wei
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yan Ge
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Yan Ge ; orcid.org/0000-0003-4378-6990
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29
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Anti-Inflammatory and/or Anti-Fibrotic Treatment of MPO-ANCA-Positive Interstitial Lung Disease: A Short Review. J Clin Med 2022; 11:jcm11133835. [PMID: 35807120 PMCID: PMC9267459 DOI: 10.3390/jcm11133835] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/27/2022] [Accepted: 06/30/2022] [Indexed: 11/30/2022] Open
Abstract
The presence of a lung lesion is common in microscopic polyangiitis (MPA), and interstitial lung disease (ILD) can lead to a poor prognosis. Although myeloperoxidase antineutrophil cytoplasmic antibodies (MPO-ANCA) are often present in patients with MPA, patients with ILD and MPO-ANCA positivity but without other manifestations of systemic vasculitis have also been reported. Therefore, the possible association between MPO-ANCA, MPA, and idiopathic ILD remains unclear. This problematic matter has influenced the treatment strategy of MPO-ANCA-positive ILD patients without systemic vasculitis. Clinicians should undertake treatment with careful consideration of the four major causes of death in MPO-ANCA-positive ILD: acute exacerbation of ILD, progressive lung fibrosis, infectious comorbidities, and diffuse alveolar hemorrhage. Further, clinicians need to carefully judge whether inflammation or fibrosis is the dominant condition with reference to the patient’s clinical domain and radiopathological lung features. Recently, anti-fibrotic agents such as nintedanib and pirfenidone were shown to be effective in treating various etiologies associated with ILD and have thus led to the widening of treatment options. In this review, the clinical characteristics, radiopathology, prognosis, and therapeutic options in patients with MPO-ANCA-positive ILD are summarized using limited information from previous studies.
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30
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Hoffmann T, Oelzner P, Franz M, Teichgräber U, Renz D, Förster M, Böttcher J, Kroegel C, Schulze PC, Wolf G, Pfeil A. Assessing the diagnostic value of a potential screening tool for detecting early interstitial lung disease at the onset of inflammatory rheumatic diseases. Arthritis Res Ther 2022; 24:107. [PMID: 35551650 PMCID: PMC9097403 DOI: 10.1186/s13075-022-02786-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 04/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interstitial lung disease (ILD) is a severe pulmonary complication in inflammatory rheumatic diseases (IRD) and associated with significantly increased morbidity and mortality. That is why ILD screening at a very early stage, at the onset of IRD, is essential. The objective of the present study was to evaluate the diagnostic value and utility of a stepwise approach as a potential ILD screening tool in patients with newly diagnosed IRD. METHODS Consecutively, 167 IRD patients were enrolled. To homogenize the study cohort, an age and gender matching was performed. The case-control study included 126 patients with new onset of IRD (mainly connective tissue diseases [CTD], small vessel vasculitis, and myositis). We applied a stepwise screening algorithm in which all patients underwent pulmonary function testing (PFT) and/or additional chest radiography. If there was at least one abnormal finding, pulmonary high-resolution computed tomography (HRCT) was subsequently performed. RESULTS With our stepwise diagnostic approach, we identified 63 IRD patients with ILD (ILD group) and 63 IRD patients without ILD (non-ILD group). A reduced diffusing capacity for carbon monoxide (DLCO) < 80% showed a sensitivity of 83.6% and a specificity of 45.8% compared to chest X-ray with 64.2% and 73.6%, respectively, in detecting ILD. The combination of reduced DLCO and chest X-ray revealed a sensitivity of 95.2% and a specificity of 38.7%. The highest sensitivity (95.2%) and specificity (77.4%) were observed for the combination of reduced DLCO, chest X-ray, and pulmonary HRCT. The most common pulmonary abnormalities on HRCT were ground-glass opacities (GGO; 36.5%), followed by non-specific interstitial pneumonia (NSIP; 31.8%) and usual interstitial pneumonia (UIP; 9.5%). CONCLUSIONS The combination of reduced DLCO (< 80%), chest X-ray, and pulmonary HRCT yielded the highest sensitivity and specificity in detecting ILD at the onset of IRD. Therefore, this stepwise approach could be a new screening algorithm to identify IRD patients with pulmonary involvement already at the time of the initial IRD diagnosis.
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Affiliation(s)
- Tobias Hoffmann
- Department of Internal Medicine III, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany.
| | - Peter Oelzner
- Department of Internal Medicine III, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine I, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Ulf Teichgräber
- Institute of Diagnostic and Interventional Radiology, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Diane Renz
- Institute of Diagnostic and Interventional Radiology, Department of Pediatric Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Martin Förster
- Department of Internal Medicine I, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Joachim Böttcher
- Department of Internal Medicine III, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Claus Kroegel
- Department of Internal Medicine I, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - P Christian Schulze
- Department of Internal Medicine I, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Gunter Wolf
- Department of Internal Medicine III, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Alexander Pfeil
- Department of Internal Medicine III, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
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Traila D, Marc MS, Pescaru C, Manolescu D, Fira-Mladinescu O. ANCA-associated vasculitis in idiopathic pulmonary fibrosis: A case report and brief review of the literature. Medicine (Baltimore) 2022; 101:e29008. [PMID: 35244078 PMCID: PMC8896427 DOI: 10.1097/md.0000000000029008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/16/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Idiopathic pulmonary fibrosis (IPF) is a progressive disease with poor prognosis. Patients with IPF represent a heterogeneous population with several described clinical phenotypes. More recently, the development of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis in IPF patients, with an incidence higher than that in the general population, has drawn attention. PATIENT CONCERNS A 64-year-old woman previously diagnosed with IPF presented to the emergency department with hemoptysis and hypoxemic respiratory failure. DIAGNOSES High-resolution chest computed tomography revealed bilateral ground-glass opacities associated with areas of consolidation superimposed on the patient's fibrotic background pattern. Diffuse alveolar hemorrhage was confirmed by the presence of hemorrhagic bronchoalveolar lavage fluid. Hematological and biochemical investigations revealed an inflammatory syndrome, moderate anemia, and rapidly progressive glomerulonephritis. Serological analysis revealed perinuclear antineutrophil cytoplasmic antibody positivity and high levels of antimyeloperoxidase antibodies antibodies. The patient underwent kidney biopsy, which revealed necrotizing glomerulonephritis. Clinical and laboratory findings were diagnostic of microscopic polyangiitis with lung and renal involvement. INTERVENTIONS Cyclophosphamide in combination with methylprednisolone was administered as remission induction therapy. The maintenance therapy consisted of mycophenolate mofetil and prednisone. OUTCOMES The patient achieved clinical, radiological, and serological remission within six weeks of treatment. LESSONS The association between IPF and ANCA-associated vasculitis may represent a distinct clinical phenotype. Autoimmune testing for ANCAs should be considered part of the diagnostic work-up and follow-up of patients with IPF because of the clinical and therapeutic implications of developing vasculitis in an already vulnerable patient.
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Affiliation(s)
- Daniel Traila
- XIIIth Department of Pulmonology, Center for Research and Innovation in Precision Medicine of Respiratory Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Timişoara, Romania
- Expert Centre for Lung Rare Diseases, Clinical Hospital of Infectious Diseases and Pneumophthisiology “Dr. Victor Babes” Timisoara, Timisoara, Romania
| | - Monica Steluta Marc
- XIIIth Department of Pulmonology, Center for Research and Innovation in Precision Medicine of Respiratory Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Timişoara, Romania
- Expert Centre for Lung Rare Diseases, Clinical Hospital of Infectious Diseases and Pneumophthisiology “Dr. Victor Babes” Timisoara, Timisoara, Romania
| | - Camelia Pescaru
- XIIIth Department of Pulmonology, Center for Research and Innovation in Precision Medicine of Respiratory Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Timişoara, Romania
- Expert Centre for Lung Rare Diseases, Clinical Hospital of Infectious Diseases and Pneumophthisiology “Dr. Victor Babes” Timisoara, Timisoara, Romania
| | - Diana Manolescu
- XIIIth Department of Pulmonology, Center for Research and Innovation in Precision Medicine of Respiratory Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Timişoara, Romania
- Expert Centre for Lung Rare Diseases, Clinical Hospital of Infectious Diseases and Pneumophthisiology “Dr. Victor Babes” Timisoara, Timisoara, Romania
| | - Ovidiu Fira-Mladinescu
- XIIIth Department of Pulmonology, Center for Research and Innovation in Precision Medicine of Respiratory Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Timişoara, Romania
- Expert Centre for Lung Rare Diseases, Clinical Hospital of Infectious Diseases and Pneumophthisiology “Dr. Victor Babes” Timisoara, Timisoara, Romania
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Santacruz-Sandoval E, López-Bonilla J, Guevara-Calderón LA, Nieto-Aristizábal I, Ruiz-Ordoñez I, Cañas CA, Santos VA, Tobón GJ, Aguirre-Valencia D. Clinical Characteristics and Outcomes of Patients With ANCA-Associated Vasculitides in a Colombian Hospital. J Clin Rheumatol 2022; 28:e491-e497. [PMID: 35192595 DOI: 10.1097/rhu.0000000000001775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/OBJECTIVE Antineutrophil cytoplasmic antibody-associated vasculitides (AAVs) are uncommon systemic autoimmune diseases, of which few reports exist in Latin America. Our aim was to examine AAV evaluated in a high-complexity hospital in southwestern Colombia, with emphasis in severe forms. METHODS A medical records review study of 67 patients was performed, and data were collected from electronic registries. Moderate and severe AAVs were defined as the presence of life-threatening complications, unfavorable Birmingham Vasculitis Activity Score outcomes, and hospitalization requirements at the time of diagnosis and by the last follow-up, between 2011 and 2019. Clinical manifestations, treatment, and outcomes were evaluated. The AAV subtypes were compared. RESULTS A total of 67 cases were included. The majority were female (n = 44, 65.67%), and the median age was 52 (40-64) years. Granulomatosis with polyangiitis (GPA) was the most frequent with 42 patients (62.68%), followed by microscopic polyangiitis (MPA) and eosinophilic GPA, with 15 patients (22.38%) and 10 patients (14.92%), respectively. Forty-four patients (65.67%) presented pulmonary symptoms. The highest Birmingham Vasculitis Activity Score corresponded to MPA, with 21 (12-25) points. Fifteen patients (22.4%) were admitted to the intensive care unit throughout the course of the disease, of whom 10 had GPA. The longest stay and duration of mechanical ventilation were seen in MPA. The principal treatments were corticosteroids and cyclophosphamide, and the main outcome was end-stage renal disease. CONCLUSIONS In this cohort of AAV, most of cases corresponded to GPA, and pulmonary manifestations were the most common. Microscopic polyangiitis was the more severe subtype as it showed worse impairment in clinical characteristics and intensive care unit requirements.
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Affiliation(s)
| | | | | | | | | | | | - Víctor A Santos
- Unit of Rheumatology, Department of Internal Medicine, Medical School, Universidad Icesi, Cali, Colombia
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d’Alessandro M, Conticini E, Bergantini L, Cameli P, Cantarini L, Frediani B, Bargagli E. Neutrophil Extracellular Traps in ANCA-Associated Vasculitis and Interstitial Lung Disease: A Scoping Review. Life (Basel) 2022; 12:life12020317. [PMID: 35207604 PMCID: PMC8877891 DOI: 10.3390/life12020317] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/10/2022] [Accepted: 02/19/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Deregulated neutrophil extracellular traps (NETs) formation is implicated in various diseases, including ANCA-associated vasculitis and pulmonary fibrosis (PF). Lung involvement is frequent in AAV, and interstitial lung diseases (ILDs) are strongly related to MPO-ANCA positivity and mainly reported in microscopic polyangiitis. The association between AAV and ILD is a strong indicator of poor prognosis and limited survival. Neutrophils, ANCA and NET interplay in PF development in AAV. This study aimed to review the literature concerning the implications of NET in lung fibrogenesis specifically focused on AAV associated with ILD, and the potential of NET as a theranostic marker. Methods: Through scoping review methodology, we used a descriptive thematic analysis to understand the pathogenic role of NETs in patients with AAV and pulmonary fibrosis and their further role as a theranostic marker of this disease. Results: The implications of NET in the pathogenesis of AAV and ILD, as well as an association between these two diseases, have been identified, but the underlying pathophysiological mechanisms are still unknown. The pharmacological or genetic inhibition of NET release reduces disease severity in multiple inflammatory disease models, indicating that NETs are potential therapeutic targets. In this regard, despite the lack of clinical data, we may hypothesise that an optimal management of AAV-ILD patients would require not only B-cells targeted therapy, but also NETs inhibition. Conclusion: Preliminary findings seem to display a lack of efficacy of traditional immunosuppressants, such as Rituximab, in this subset of patients, while to date no patients suffering from a definite ILD have been enrolled in clinical trials. Further insights would be provided by their employment, as a combination treatment, in common clinical practice. Although we can imagine that the inhibition of NETs in patients with AAV-ILD could reduce severity and mortality, we still lack the scientific basis that could improve our understanding of the disease from a molecular point of view.
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Affiliation(s)
- Miriana d’Alessandro
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy; (M.d.); (L.B.); (P.C.); (E.B.)
| | - Edoardo Conticini
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100 Siena, Italy; (L.C.); (B.F.)
- Correspondence:
| | - Laura Bergantini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy; (M.d.); (L.B.); (P.C.); (E.B.)
| | - Paolo Cameli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy; (M.d.); (L.B.); (P.C.); (E.B.)
| | - Luca Cantarini
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100 Siena, Italy; (L.C.); (B.F.)
| | - Bruno Frediani
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100 Siena, Italy; (L.C.); (B.F.)
| | - Elena Bargagli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy; (M.d.); (L.B.); (P.C.); (E.B.)
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Kimbrough BA, Baqir M, Johnson TF, Vasireddy A, Ryu JH. Interstitial Lung Disease in Giant Cell Arteritis: Review of 23 Patients. J Clin Rheumatol 2022; 28:e3-e8. [PMID: 32925448 DOI: 10.1097/rhu.0000000000001566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Giant cell arteritis (GCA) is a large-vessel vasculitis with systemic manifestations. A few case reports have described a possible association of GCA with interstitial lung disease (ILD). The primary aim of the present study was to describe the pattern, severity, and course of ILD in patients with GCA. METHODS This medical records review study evaluated adult patients presenting to Mayo Clinic in Rochester, MN, from January 1, 1997, through December 31, 2018, who had the diagnoses of GCA and ILD. Clinical, laboratory, and radiologic data were analyzed. RESULTS In total, 23 patients were in the study. Median (range) age was 78 (58-93) years, and 14 (61%) were women. Six patients (26%) had a cough at GCA diagnosis. At ILD diagnosis, 15 patients had respiratory symptoms, including dyspnea (n = 12, 52%), dry cough (n = 6, 26%), wheezing (n = 1, 4%), and chest pain (n = 1, 4%). On initial chest computed tomography, the most common pattern of ILD was probable usual interstitial pneumonia (n = 7, 30%), indeterminate for usual interstitial pneumonia (n = 5, 22%), and combined pulmonary fibrosis and emphysema (n = 3, 13%). Airway abnormalities were present in 10 patients: 6 with bronchial wall thickening, 2 with bronchiectasis, and 2 with both. At follow-up computed tomography, 8 patients had ILD progression. Three patients with cough improved after initiation of glucocorticoid therapy. CONCLUSIONS Interstitial lung disease and airway abnormalities may be associated with GCA. Although cough may improve, ILD in some patients with GCA may progress despite immunosuppressive therapy.
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Affiliation(s)
| | - Misbah Baqir
- Division of Pulmonary and Critical Care Medicine
| | | | - Amit Vasireddy
- Department of Internal Medicine, Berkshire Medical Center, Pittsfield, MA
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine
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Pediatric cardiothoracic vasculitis: multimodality imaging review. Pediatr Radiol 2022; 52:1895-1909. [PMID: 35790558 PMCID: PMC9256530 DOI: 10.1007/s00247-022-05431-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/19/2022] [Accepted: 06/13/2022] [Indexed: 10/27/2022]
Abstract
The pediatric vasculitides are a relatively uncommon and heterogeneous group of disorders characterized by vessel inflammation, often with cardiothoracic involvement. Diagnosis and monitoring are often clinically challenging because of the nonspecific symptoms and laboratory markers. Thus, imaging has assumed increasing importance for early detection of disease activity, extent and complications as well as long-term monitoring pre- and post-treatment. Herein, we review the major pediatric vasculitides with frequent chest manifestations, including Takayasu arteritis, Kawasaki disease, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis, Behçet disease and potential mimics. We highlight key clinical features and management considerations, emphasizing the central role of imaging.
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Kadura S, Raghu G. Antineutrophil cytoplasmic antibody-associated interstitial lung disease: a review. Eur Respir Rev 2021; 30:30/162/210123. [PMID: 34750115 DOI: 10.1183/16000617.0123-2021] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/24/2021] [Indexed: 12/26/2022] Open
Abstract
Over the past three decades, an increasing number of publications have reported the association between interstitial lung disease (ILD) and anti-neutrophil cytoplasmic antibody (ANCA) or ANCA-associated vasculitis (AAV). With this increased awareness, we have reviewed the literature to date and provide an update in this narrative review. The vast majority of cases of ILD have been shown to be in the setting of positive anti-myeloperoxidase antibody and can be present in up to 45% of patients of microscopic polyangiitis, though cases of ILD associated with proteinase 3 ANCA have rarely been reported. Pulmonary fibrosis and ANCA positivity can occur with or without systemic involvement. The pathogenetic mechanisms establishing the relationship between ANCA and the development of pulmonary fibrosis remain unclear. Histologic and radiographic features of ANCA-ILD most commonly reveal usual interstitial pneumonia or non-specific interstitial pneumonia patterns, though other atypical features such as bronchiolitis have been described. ILD in the setting of AAV has been associated with worse outcomes, and thus early identification and treatment in these patients is appropriate. We advocate that ANCA antibody testing be performed as a baseline evaluation in patients presenting with idiopathic interstitial pneumonia. Suggested treatment of ANCA-ILD includes immunosuppression and/or antifibrotic agents, though supporting data and clinical trials to substantiate use of these therapies are needed.
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Affiliation(s)
- Suha Kadura
- Dept of Medicine, Center for Interstitial Lung Diseases, University of Washington, Seattle, WA, USA
| | - Ganesh Raghu
- Dept of Medicine, Center for Interstitial Lung Diseases, University of Washington, Seattle, WA, USA
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Pulmonary Vasculitides: A Radiological Review Emphasizing Parenchymal HRCT Features. Diagnostics (Basel) 2021; 11:diagnostics11122318. [PMID: 34943555 PMCID: PMC8700038 DOI: 10.3390/diagnostics11122318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 11/23/2022] Open
Abstract
Vasculitides represent a heterogeneous group of immune-mediated disorders, characterized by a systemic inflammatory destructive process of the blood vessels resulting either in ischemia or hemorrhage. The organ involved and vessel size influence the pattern of presentation of the pathology. The lung is commonly involved in systemic vasculitides, with heterogeneous clinical, radiological, and histopathological presentations. Primary vasculitides most commonly associated with lung parenchymal involvement include small-vessel antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides, such as granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA), and microscopic polyangiitis (MPA). Several studies have reported cases of interstitial lung diseases (ILDs) associated with systemic vasculitis, particularly those positive for ANCA associated vasculitis/vasculitidis: AAV. We have selected from our case series different radiological features of pulmonary vasculitis (i.e., solitary or multiple nodules, cavitary lesions, nodules with centrilobular or peribronchial distribution, airspace consolidations, “crazy paving” appearance, interstitial disease), including cases with interstitial lung alterations. Therefore, the aim of this review is to describe the typical clinical manifestations of vasculitides and their main radiologic features (especially AAV).
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Kwon M, Lee AS, Mira-Avendano I, Rojas CA, Grage R, Abril A. Interstitial Lung Disease in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Patients: Comparison With Idiopathic Pulmonary Fibrosis. J Clin Rheumatol 2021; 27:324-330. [PMID: 32251058 DOI: 10.1097/rhu.0000000000001357] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) may involve the kidney, respiratory tract, skin, or central and peripheral nervous system. Reports of interstitial lung disease (ILD) in AAV (AAV-ILD) have been increasing. METHODS We reviewed the medical records of all patients with AAV-ILD between January 1, 2007, and December 31, 2017, and compared their pulmonary involvement to patients with idiopathic pulmonary fibrosis (IPF). RESULTS We identified 24 patients with AAV-ILD: 14 with microscopic polyangiitis, 8 with granulomatosis with polyangiitis, and 2 with eosinophilic granulomatosis with polyangiitis. Perinuclear or myeloperoxidase ANCA was present in 16 cases (66.7%), whereas cytoplasmic or proteinase 3 ANCA was positive in 8 (33.3%). Usual interstitial pneumonia (UIP) was seen in 11 (45.8%), probable UIP in 1 (4.2%), indeterminate UIP in 2 (8.3%), and an alternate diagnosis in 10 (41.7%), and was further characterized as chronic hypersensitivity pneumonitis-like pattern seen in 6 (25%), nonspecific interstitial pneumonia-like pattern in 3 (12.5%), and cryptogenic organizing pneumonia-like pattern in 1 (4.2%). Forced vital capacity and diffusing capacity declined over time in patients with AAV-ILD. When compared with the IPF cohort, patients with AAV-ILD had intermediate survival and speed of lung function decline (3-year survival in AAV-ILD group was 94% vs 69% in IPF). CONCLUSIONS Antineutrophil cytoplasmic antibody-associated vasculitis ILD is a progressive and potentially fatal condition. Although most cases in the literature are associated with p-ANCA and positive myeloperoxidase, we found that a third of patients had c-ANCA or granulomatosis with polyangiitis. Our cohort adds experience in this rare manifestation of AAV.
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Affiliation(s)
- Minkyung Kwon
- From the Division of Pulmonary, Allergy, and Sleep Medicine
| | | | | | | | | | - Andy Abril
- Division of Rheumatology, Mayo Clinic, Jacksonville, FL
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Zhang Y, Guo J, Zhang P, Zhang L, Duan X, Shi X, Guo N, Liu S. Predictors of Mortality in Critically Ill Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Front Med (Lausanne) 2021; 8:762004. [PMID: 34760903 PMCID: PMC8573203 DOI: 10.3389/fmed.2021.762004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/28/2021] [Indexed: 01/29/2023] Open
Abstract
Background: Patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV) may require intensive care unit (ICU) admission due to different reasons, and the in-ICU mortality is high among AAV patients. The aim of this study was to explore the clinical features and risk factors of mortality of patients with AAV in the ICU. Methods: A retrospective study was conducted based on 83 AAV patients admitted to the ICU in a tertiary medical institution in China. Data on clinical characteristics, laboratory tests, treatment in ICU and outcomes were collected. The data were analyzed using univariate and multivariate logistic regression analysis to explore the variables that were independently related to mortality. Kaplan–Meier method was used to assess the long-term survival. Results: Among the 83 patients, 41 (49.4%) were female. The mean age of patients was 66 ± 13 years. Forty-four patients deceased, with the in-ICU mortality of 53%. The most common cause for ICU admission was active vasculitis (40/83, 48.2%). The main cause of death was infection (27/44, 61.4%) followed by active vasculitis (15/44, 34.1%). A multivariate analysis revealed that the Acute Physiology and Chronic Health Evaluation II (APACHE II) at ICU admission (OR = 1.333, 95% CI: 1.031–1.722) and respiratory failure (OR = 620.452, 95% CI: 11.495–33490.306) were independent risk factors of in-ICU death. However, hemoglobin (OR = 0.919, 95% CI: 0.849–0.995) was an independent protective factor. The nomogram established in this study was practical in predicting the risk of in-ICU mortality for AAV patients. Moreover, for 39 patients survived to the ICU stay, the cumulative survival rates at 0.5, 1, and 5 years were 58.3%, 54.2%, and 33.9%, respectively, and the median survival time was 14 months. Conclusion: In our study, active vasculitis was the most frequent reason for ICU admission, and the main cause of death was infection. APACHE II and respiratory failure were independent risk factors while hemoglobin was an independent protective factor of in-ICU mortality for AAV patients admitted to the ICU. The risk prediction model developed in this study may be a useful tool for clinicians in early recognition of high-risk patients and applying appropriate management.
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Affiliation(s)
- Yuqi Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jinyan Guo
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Panpan Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lei Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaoguang Duan
- Department of Intensive Care Unit, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaofei Shi
- Department of Rheumatology, the First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, China
| | - Nailiang Guo
- Department of Rheumatology and Immunology, Xinyang Central Hospital, Xinyang, China
| | - Shengyun Liu
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Yamakawa H, Sato S, Nakamura T, Nishizawa T, Kawabe R, Oba T, Horikoshi M, Akasaka K, Amano M, Kuwano K, Sasaki H, Matsushima H. Prognostic value of radiological findings indeterminate for UIP pattern and anterior upper lobe honeycomb-like lesion in chronic fibrosing interstitial lung disease associated with MPO-ANCA. BMC Pulm Med 2021; 21:346. [PMID: 34732182 PMCID: PMC8565010 DOI: 10.1186/s12890-021-01718-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 10/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA) is often positive in patients with interstitial lung disease (ILD), which is also often present in patients with microscopic polyangiitis (MPA). A possible association between MPO-ANCA, MPA, and idiopathic ILD remains unclear. The objective of this study was to determine whether high-resolution computed tomography (HRCT) classification based on recent idiopathic pulmonary fibrosis guideline and specific CT findings can obtain new knowledge of prognostic factors in all MPO-ANCA-positive patients with ILD including both idiopathic ILD and MPA-ILD. Methods We analyzed 101 consecutive MPO-ANCA-positive patients with respiratory disease. We assessed the diagnostic accuracy of CT findings, HRCT pattern, and specific radiological signs. Prognostic predictors were determined using Cox regression models. Results Subjects with chronic ILD included 22 patients with MPA-ILD and 39 patients with ILD but without MPA. A quarter of the patients were radiological indeterminate for usual interstitial pneumonia (UIP) pattern, which resulted in a better prognosis than that for UIP pattern. “Increased attenuation around honeycomb and traction bronchiectasis” and “anterior upper lobe honeycomb-like lesion” were found to be highly frequent radiological findings (39% and 30%, respectively). In addition, the latter finding was a significant negative prognostic factor. Conclusions Radiological indeterminate for UIP was a useful HRCT classification in MPO-ANCA-positive patients with ILD. In addition, anterior upper lobe honeycomb-like lesion was found to be specific radiological finding that was a significant prognostic factor. The present results might aid in the assessment of appropriate strategies of diagnosis in these patients.
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Affiliation(s)
- Hideaki Yamakawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan. .,Department of Respiratory Medicine, Tokyo Jikei University Hospital, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Shintaro Sato
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Tomohiko Nakamura
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Tomotaka Nishizawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Rie Kawabe
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Tomohiro Oba
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Masanobu Horikoshi
- Department of Rheumatology, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Keiichi Akasaka
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Masako Amano
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Kazuyoshi Kuwano
- Department of Respiratory Medicine, Tokyo Jikei University Hospital, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroki Sasaki
- Department of Radiology, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Hidekazu Matsushima
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
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Hu H, Keat K. Myeloperoxidase and associated lung disease: Review of the latest developments. Int J Rheum Dis 2021; 24:1460-1466. [PMID: 34498802 DOI: 10.1111/1756-185x.14213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/25/2021] [Indexed: 12/21/2022]
Abstract
Myeloperoxidase (MPO) anti-neutrophil cytoplasmic antibodies (ANCA) are often detected in association with a variety of lung pathologies, the most common being interstitial lung disease (ILD). A growing cohort of patients are being diagnosed with MPO-ANCA in the context of ILD without ANCA-associated vasculitis. Clinically and radiologically, there is little to differentiate this cohort from MPO-ANCA-negative ILD patients; however, the pathophysiology is likely different and different treatments are likely required. We present here a brief summary of the proposed pathophysiology of MPO-ANCA-positive ILD, and a more detailed review of the latest evidence on management, including monitoring for development of ANCA-associated vasculitis, immunosuppression, anti-fibrotics, and novel agents that have yet to be trialled in human experiments.
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Affiliation(s)
- Hannah Hu
- Department of Immunology, Campbelltown Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Karuna Keat
- Department of Immunology, Campbelltown Hospital, Sydney, New South Wales, Australia.,Western Sydney University, Sydney, New South Wales, Australia
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Kim MJ, Shin K. Interstitial Lung Disease and Diffuse Alveolar Hemorrhage, the Two Key Pulmonary Manifestations in Microscopic Polyangiitis. Tuberc Respir Dis (Seoul) 2021; 84:255-262. [PMID: 34418915 PMCID: PMC8497773 DOI: 10.4046/trd.2021.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/07/2021] [Indexed: 11/24/2022] Open
Abstract
Microscopic polyangiitis (MPA) is an antineutrophil cytoplasmic antibody (ANCA)‒associated necrotizing vasculitis, which mainly affects small vessels in various organs, especially the lungs. The two key pulmonary manifestations, interstitial lung disease (ILD) and diffuse alveolar hemorrhage (DAH), increase the morbidity and death rate of patients with MPA. ILD is more common in MPA than in other ANCA-associated vasculitis subsets and is primarily associated with myeloperoxidase-ANCA. Unlike alveolar hemorrhage due to pulmonary capillaritis, ILD can initially manifest as isolated pulmonary fibrosis. Of note, its most frequent radiographic pattern is the usual interstitial pneumonia pattern, similar to the characteristic pattern seen in idiopathic pulmonary fibrosis. In this review we present the pathogenesis, clinical manifestations, and radiographic and histopathologic features of ILD and DAH in MPA. We also briefly summarize the outcome and therapeutic options for the two conditions.
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Affiliation(s)
- Min Jung Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National Boramae Medical Center, Seoul, Republic of Korea
| | - Kichul Shin
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National Boramae Medical Center, Seoul, Republic of Korea
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Kuwana M, Gil-Vila A, Selva-O’Callaghan A. Role of autoantibodies in the diagnosis and prognosis of interstitial lung disease in autoimmune rheumatic disorders. Ther Adv Musculoskelet Dis 2021; 13:1759720X211032457. [PMID: 34377160 PMCID: PMC8320553 DOI: 10.1177/1759720x211032457] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/25/2021] [Indexed: 12/17/2022] Open
Abstract
Interstitial lung disease (ILD) has been recognized as a frequent manifestation associated with a substantial morbidity and mortality burden in patients with autoimmune rheumatic disorders. Serum autoantibodies are considered good biomarkers for identifying several subsets or specific phenotypes of ILD involvement in these patients. This review features the role of several autoantibodies as a diagnostic and prognostic biomarker linked to the presence ILD and specific ILD phenotypes in autoimmune rheumatic disorders. The case of the diverse antisynthetase antibodies in the antisynthease syndrome or the anti-melanoma differentiation-associated 5 protein (MDA5) antibodies as a marker of a severe condition such as rapidly progressive ILD in patients with clinically amyopathic dermatomyositis are some of the associations herein reported in the group of myositis spectrum disorders. Specific autoantibodies such as the well-known anti-topoisomerase I (anti-Scl70) or the anti-Th/To, anti-U11/U12 ribonucleoprotein, and anti-eukaryotic initiation factor 2B (eIF2B) antibodies seems to be specifically linked to ILD in patients with systemic sclerosis. Overlap syndromes between systemic sclerosis and myositis, also have good ILD biomarkers, which are the anti-PM/Scl and anti-Ku autoantibodies. Lastly, other not so often reported disorders as being associated with ILD but recently most recognized as is the case of rheumatoid arthritis associated ILD or entities herein included in the miscellaneous disorders section, which include anti-neutrophil cytoplasmic antibody-associated interstitial lung disease, Sjögren's syndrome or the mixed connective tissue disease, are also discussed.
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Affiliation(s)
- Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine; Scleroderma/Myositis Center of Excellence (SMCE) Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Albert Gil-Vila
- Systemic Autoimmune Diseases Unit, Vall d’Hebron General Hospital, Medicine Dept, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Albert Selva-O’Callaghan
- Systemic Autoimmune Diseases Unit, Vall d’Hebron General Hospital, Medicine Dept, Universitat Autónoma de Barcelona, Barcelona, Spain
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44
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Interstitial pneumonia with autoimmune features: from research classification to diagnosis. Curr Opin Pulm Med 2021; 27:374-387. [PMID: 34183525 DOI: 10.1097/mcp.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The term interstitial pneumonia with autoimmune features (IPAF) was first proposed by an international task force in 2015 as a research classification to standardise nomenclature regarding patients with idiopathic interstitial pneumonia and features of connective tissue disease. However, how the use of this term and its proposed definition translates to clinical practice remains uncertain. This review will provide a comprehensive overview of studies of IPAF cohorts to date, discuss the consideration of IPAF as a distinct diagnostic entity and outline a suggested approach to patient management. RECENT FINDINGS Considerable heterogeneity exists between published IPAF cohorts, with some cohorts exhibiting similarities to those with connective tissue disease-associated interstitial lung disease (CTD-ILD), and others more similar to idiopathic interstitial pneumonias including idiopathic pulmonary fibrosis (IPF). Little data exist to inform the management of patients who fulfil the IPAF criteria. Preliminary data supports pragmatic management of these patients as having a working clinical diagnosis of either idiopathic interstitial pneumonia or CTD-ILD. Future research studies into this approach are required. SUMMARY The term IPAF, and its definition, have been of fundamental benefit to facilitating research in this diverse patient group. However, to date, there remain many unanswered questions regarding their natural histories and response to treatment.
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Fidler LM, Kandel S, Fisher JH, Mittoo S, Shapera S. Utility of anti-neutrophil cytoplasmic antibody screening in idiopathic interstitial lung disease. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2021; 38:e2021015. [PMID: 34316255 PMCID: PMC8288199 DOI: 10.36141/svdld.v38i2.10971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 06/15/2021] [Indexed: 11/23/2022]
Abstract
Background: Interstitial lung disease (ILD) is an established manifestation of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Autoimmune serologic screening is recommended by international consensus guidelines during the evaluation of idiopathic ILD, but ANCA testing only on a case-by-case basis. Objective: We aimed to evaluate the role of ANCA screening in patients with idiopathic ILD. Methods: We performed a retrospective review of patients seen between September 2015 and April 2017 in the ILD clinic at Toronto General Hospital. Patients referred with confirmed or suspected connective tissue disease were excluded. Patient demographics, symptoms, chest imaging, and pulmonary function testing was collected. We performed descriptive statistics based on the presence of ANCAs and estimated operating characteristics for ANCA screening. Results: In total, 360 patients with idiopathic ILD were reviewed, 159 met study inclusion criteria and 4 (2.5%) tested positive for ANCAs. Two patients (1.2%) had elevated myeloperoxidase-ANCAs (MPO-ANCA) and 2 (1.2%) had elevated proteinase-3-ANCAs (PR3-ANCA). There were no significant associations between patient demographics and ANCAs. One patient (0.6%) with PR3-ANCAs was diagnosed with vasculitis following rheumatologic evaluation. Despite negative ANCA testing, 1 patient (0.6%) was diagnosed with vasculitis following rheumatologic evaluation. The sensitivity and specificity of ANCA screening for vasculitis in patients with ILD was calculated as 50% (95% CI, 1.3%-98.7%) and 98% (95%CI, 4.4-155.5) respectively. Negative and positive likelihood ratios were 0.5 (95%CI 0.1-2.0) and 26.2 (95%CI 4.4-155.5) respectively. Conclusion: ANCA screening in patients with idiopathic ILD rarely yields positive results. These results support an individualized approach to ANCA testing as opposed to widespread screening.
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Affiliation(s)
- Lee M Fidler
- University Health Network, Department of Medicine, Division of Respirology, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Department of Medicine, Division of Respirology, Toronto, Ontario, Canada.,University of Toronto, Department of Medicine
| | - Sonja Kandel
- University Health Network, Department of Radiology, Toronto, Ontario, Canada
| | - Jolene H Fisher
- University Health Network, Department of Medicine, Division of Respirology, Toronto, Ontario, Canada.,University of Toronto, Department of Medicine
| | - Shikha Mittoo
- University Health Network, Department of Medicine, Division of Rheumatology, Toronto, ON, Canada
| | - Shane Shapera
- University Health Network, Department of Medicine, Division of Respirology, Toronto, Ontario, Canada.,University of Toronto, Department of Medicine
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46
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Deshayes S, Dolladille C, Dumont A, Martin Silva N, Chretien B, De Boysson H, Alexandre J, Aouba A. A worldwide pharmacoepidemiological update of drug-associated ANCA-associated vasculitis at the time of targeted therapies. Arthritis Rheumatol 2021; 74:134-139. [PMID: 34164938 DOI: 10.1002/art.41902] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/10/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The literature data supporting the role of a drug in the onset of drug-associated anti-neutrophil cytoplasmic antibody-associated vasculitis (DA-AAV) mainly rely on case reports or short series and implicate old treatments. The advent of new treatments may have modified the epidemiology of these adverse drug reactions (ADRs). We therefore aimed to update this list by using a pharmacovigilance-based data mining approach. METHODS We collected data on ADRs reported with the MedDRA preferred term "Anti-neutrophil cytoplasmic antibody positive vasculitis" up to November 2020 from the World Health Organization pharmacovigilance database (VigiBase® ). For each retrieved drug, a case/noncase analysis was performed, and disproportionate reporting was calculated by using the information component (IC). A positive IC025 value, which is the lower end of the 95% credibility interval, was considered significant. RESULTS A total of 483 deduplicated individual case safety reports of DA-AAV involving 15 drugs with an IC025 >0 were retrieved. DA-AAV occurred in 264 (71.2%, n=371) women, the median age at onset was 62 years [45-72], and the median time to onset between the introduction of the suspected drug and DA-AAV was 9 months [1-36]. DA-AAV occurrence was considered serious in 472 (97.7%, n=481) cases and fatal in 43 (8.9%) cases. The drugs associated with the highest disproportionate reporting were hydralazine, propylthiouracil, thiamazole, sofosbuvir, minocycline, carbimazole, mirabegron, and nintedanib. CONCLUSION This study strengthens the previously suspected association but also identifies 3 new drugs that may cause DA-AAV. Particular attention should be given to these drugs by prescribers and in experimental studies.
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Affiliation(s)
- Samuel Deshayes
- Department of Internal Medicine, Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000, Caen, France.,Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen Normandie, 14000, Caen, France
| | - Charles Dolladille
- Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen Normandie, 14000, Caen, France.,Department of Pharmacology, CHU de Caen Normandie, 14000, Caen, France
| | - Anaël Dumont
- Department of Internal Medicine, Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000, Caen, France
| | - Nicolas Martin Silva
- Department of Internal Medicine, Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000, Caen, France
| | - Basile Chretien
- Department of Pharmacology, CHU de Caen Normandie, 14000, Caen, France
| | - Hubert De Boysson
- Department of Internal Medicine, Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000, Caen, France.,Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen Normandie, 14000, Caen, France
| | - Joachim Alexandre
- Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen Normandie, 14000, Caen, France.,Department of Pharmacology, CHU de Caen Normandie, 14000, Caen, France
| | - Achille Aouba
- Department of Internal Medicine, Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000, Caen, France.,Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen Normandie, 14000, Caen, France
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47
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Interstitial Lung Disease and Anti-Myeloperoxidase Antibodies: Not a Simple Association. J Clin Med 2021; 10:jcm10122548. [PMID: 34207641 PMCID: PMC8227546 DOI: 10.3390/jcm10122548] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/31/2021] [Accepted: 06/07/2021] [Indexed: 11/25/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibodies (ANCA), mainly anti-myeloperoxidase (MPO) antibodies, have been frequently identified in patients with idiopathic pulmonary fibrosis (IPF). However, their role remains unclear, and only 7–23% of these patients develops clinically overt vasculitis. We aimed to investigate the clinical, serological, and radiological features and prognosis of anti-MPO-positive interstitial lung disease (ILD) patients. Fifty-eight consecutive patients firstly referred for idiopathic interstitial pneumonia and showing serological positivity of anti-MPO antibodies were retrospectively enrolled. For each patient, clinical data, lung function testing, chest high-resolution computed tomography (HRCT) pattern, and survival were recorded. Thirteen patients developed a rheumatic disease during a median follow-up of 39 months. Usual interstitial pneumonia (UIP) was the most frequent ILD pattern, significantly influencing the patients’ survival. In fact, while the 52-week survival of the overall population was 71.4 ± 7.5%, significantly higher than IPF, survivals of anti-MPO patients with UIP pattern and IPF were similar. Forced vital capacity and diffusion lung capacity for CO significantly declined in 37.7 and 41.5% of cases, respectively, while disease progression at chest HRCT was observed in 45.2%. A careful clinical history and evaluation should always be performed in ILD patients with anti-MPO antibodies to quickly identify patients who are developing a systemic rheumatic disease.
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48
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Min HK, Kim SH, Lee SH, Kim HR. Recent advances in the diagnosis and management of interstitial pneumonia with autoimmune features: the perspective of rheumatologists. Korean J Intern Med 2021; 36:515-526. [PMID: 33045807 PMCID: PMC8137388 DOI: 10.3904/kjim.2020.443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/07/2020] [Indexed: 12/29/2022] Open
Abstract
Interstitial pneumonia with autoimmune feature (IPAF) is a recently established disease entity that is comprised of interstitial lung diseases with evidence of autoimmune features but that does not fulfill the criteria for definite autoimmune rheumatic diseases. The classification criteria for IPAF were defined by the European Respiratory Society and American Thoracic Society in 2015. However, further studies to establish IPAF subgroups and treatment modalities for each subgroup are still needed. In this review, we discuss recent advances regarding IPAF and raise critical points for the diagnosis and management of patients with IPAF from the perspective of rheumatologists.
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Affiliation(s)
- Hong Ki Min
- Division of Rheumatology, Department of Internal Medicine, Konkuk University Medical Center, Seoul, Korea
| | - Se-Hee Kim
- Division of Rheumatology, Department of Internal Medicine, Konkuk University Medical Center, Seoul, Korea
| | - Sang-Heon Lee
- Division of Rheumatology, Department of Internal Medicine, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
| | - Hae-Rim Kim
- Division of Rheumatology, Department of Internal Medicine, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
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Windpessl M, Bettac EL, Gauckler P, Shin JI, Geetha D, Kronbichler A. ANCA Status or Clinical Phenotype - What Counts More? Curr Rheumatol Rep 2021; 23:37. [PMID: 33909191 PMCID: PMC8081707 DOI: 10.1007/s11926-021-01002-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW There is ongoing debate concerning the classification of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. That is, whether classification should be based on the serotype (proteinase 3 (PR3)- or myeloperoxidase (MPO)-ANCA) or on the clinical phenotype (granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA)). To add clarity, this review focused on integration of the most recent literature. RECENT FINDINGS Large clinical trials have provided evidence that a serology-based risk assessment for relapses is more predictive than distinction based on the phenotype. Research conducted in the past decade indicated that a serology-based approach more closely resembles the genetic associations, the clinical presentation (i.e., lung involvement), biomarker biology, treatment response, and is also predicting comorbidities (such as cardiovascular death). Our review highlights that a serology-based approach could replace a phenotype-based approach to classify ANCA-associated vasculitides. In future, clinical trials and observational studies will presumably focus on this distinction and, as such, translate into a "personalized medicine."
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Affiliation(s)
- Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Grieskirchnerstrasse 42, 4600, Wels, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Erica L Bettac
- Department of Psychology, Washington State University Vancouver, 14204 NE Salmon Creek Avenue, Vancouver, WA, USA
| | - Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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50
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The Role of Lung Colonization in Connective Tissue Disease-Associated Interstitial Lung Disease. Microorganisms 2021; 9:microorganisms9050932. [PMID: 33925354 PMCID: PMC8146539 DOI: 10.3390/microorganisms9050932] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/15/2021] [Accepted: 04/21/2021] [Indexed: 02/06/2023] Open
Abstract
Connective tissue diseases (CTDs) may frequently manifest with interstitial lung disease (ILD), which may severely impair quality and expectation of life. CTD-ILD generally has a chronic clinical course, with possible acute exacerbations. Although several lines of evidence indicate a relevant role of infections in the acute exacerbations of CTD-ILD, little information is available regarding the prevalence of infections in chronic CTD-ILD and their possible role in the clinical course. The aim of the present retrospective study was the identification of lung microbial colonization in broncho-alveolar lavage from patients affected by stable CTD-ILD with radiologically defined lung involvement. We demonstrated that 22.7% of patients with CTD-ILD display microbial colonization by Pseudomonas aeruginosa, Haemophilus influenzae, and non-tuberculous mycobacteria. Moreover, these patients display a major radiologic lung involvement, with higher impairment in lung function tests confirmed in a multivariate logistic regression analysis. Overall, the present study provides new information on lung colonization during CTD-ILD and its possible relationship with lung disease progression and severity.
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