1
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Becker SL, Kody S, Fett NM, Hines A, Alavi A, Ortega-Loayza AG. Approach to the Atypical Wound. Am J Clin Dermatol 2024; 25:559-584. [PMID: 38744780 DOI: 10.1007/s40257-024-00865-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
The heterogeneity of atypical wounds can present diagnostic and therapeutic challenges; however, as the prevalence of atypical wounds grows worldwide, prompt and accurate management is increasingly an essential skill for dermatologists. Addressing the underlying cause of an atypical wound is critical for successful outcomes. An integrated approach with a focus on pain management and patient engagement is recommended to facilitate enduring wound closure. Advances in treatment, in addition to further research and clinical training, are necessary to address the expanding burden of atypical wounds.
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Affiliation(s)
- Sarah L Becker
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Shannon Kody
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Nicole M Fett
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | | | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA.
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2
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Ghafari-Saravi A, Haussmann A, Wu J, Cheng K. Treatment of severe perinuclear antineutrophil cytoplasmic antibody-associated vasculitis with efgartigimod. JAAD Case Rep 2024; 47:68-71. [PMID: 38659474 PMCID: PMC11039778 DOI: 10.1016/j.jdcr.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Affiliation(s)
- Afsoon Ghafari-Saravi
- Department of Dermatology, Oregon Health & Science University, School of Medicine, Portland, Oregon
| | - Alana Haussmann
- Department of Rheumatology, University of California Los Angeles, Los Angeles, California
| | - Jessica Wu
- Department of Dermatology, University of California Los Angeles, Los Angeles, California
| | - Kyle Cheng
- Department of Dermatology, University of California Los Angeles, Los Angeles, California
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3
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Kanan K, Karat TP, Vishwajeet V, Wadhwa Y, Patra S. Pyoderma gangrenosum-like ulcers over the face in a case of granulomatosis with polyangiitis. Int J Dermatol 2023; 62:1206-1207. [PMID: 36250767 DOI: 10.1111/ijd.16456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/24/2022] [Accepted: 10/07/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Karthick Kanan
- Department of Dermatology, Venereology and Leprology, All India Institute of Medical Sciences, Jodhpur, India
| | - Thoyyib P Karat
- Department of Dermatology, Venereology and Leprology, All India Institute of Medical Sciences, Jodhpur, India
| | - Vikarn Vishwajeet
- Department of Pathology, All India Institute of Medical Sciences, Jodhpur, India
| | - Yamini Wadhwa
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Suman Patra
- Department of Dermatology, Venereology and Leprology, All India Institute of Medical Sciences, Jodhpur, India
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4
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Cutaneous Deep Ulcerations as Initial Presentations of Granulomatosis with Polyangiitis: Two Case Reports and Differential Diagnosis. Medicina (B Aires) 2023; 59:medicina59030563. [PMID: 36984564 PMCID: PMC10057340 DOI: 10.3390/medicina59030563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 03/15/2023] Open
Abstract
Background: Granulomatosis with polyangiitis (GPA) is an antineutrophil-cytoplasmic-antibody (ANCA)-associated small-vessel vasculitis characterized by necrotizing granulomatous inflammation. Symptoms of skin involvement can appear in 30–50% of patients with GPA, and may present as the initial presentation. Case Presentation: We describe two patients who presented with multiple deep, large, nonhealing skin ulcers postoperatively with purulent drainage and fever. Both patients were diagnosed with GPA after an extensive evaluation, including histopathology. Infectious, connective tissue disease and malignant etiologies were excluded. Their cANCA and PR3-ANCA levels were positive. Patient 2 was diagnosed early and recovered well after treatment with corticosteroids and rituximab; however, Patient 1 had a poor prognosis due to a long disease course. Conclusions: Diseases with multiple deep, large skin ulcers and fever can be infectious or noninfectious. Atypical manifestations may lead to missed diagnosis and misdiagnosis. GPA may initially present in a localized form before progressing to a generalized disease. The two cases we have highlighted will prompt clinicians to nevertheless call for a low threshold for diagnosis.
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5
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Shakshouk H, Gibson LE. Cutaneous manifestations of ANCA-associated vasculitis: a retrospective review of 211 cases with emphasis on clinicopathologic correlation and ANCA status. Int J Dermatol 2023; 62:231-238. [PMID: 35576100 DOI: 10.1111/ijd.16214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/13/2022] [Accepted: 03/22/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND ANCA-associated vasculitis (AAV) may present a wide array of dermatological manifestations. Patients may remain ANCA negative, rendering diagnosis challenging for dermatologists if they depend heavily on ANCA testing to either confirm or rule out AAV. OBJECTIVE To compare clinical and histopathological features of AAV patients with skin lesions who are ANCA positive versus those who are ANCA negative. METHODS Retrospective review of medical charts to identify patients diagnosed with AAV by clinical and pathologic criteria who also had cutaneous manifestations. RESULTS Search revealed that 211 out of 932 (23%) patients had cutaneous manifestations. Of those, 40/211 (20%) patients had persistently ANCA-negative serology. Eosinophilic granulomatosis with polyangiitis (EGPA) comprised the largest cohort. Palpable purpura was the most prominent clinical feature. The most common histopathological feature was leukocytoclastic vasculitis (LCV) in 19 (29%) specimens, extravascular granuloma in 14 (22%), followed by perivascular infiltrate in 12 (18%), with eosinophils in nine. In the ANCA-negative subgroup, perivascular infiltrate was more common followed by LCV but without statistically significant difference. CONCLUSIONS Diagnosis of AAV should not be based on ANCA testing alone since a considerable number of patients with cutaneous lesions may be ANCA negative. The clinical or histopathologic findings of skin lesions in this study group did not vary based on ANCA status.
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Affiliation(s)
| | - Lawrence E Gibson
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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6
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Gibson LE. Cutaneous manifestations of antineutrophil cytoplasmic antibody‐associated vasculitis (
AAV
): a concise review with emphasis on clinical and histopathologic correlation. Int J Dermatol 2022; 61:1442-1451. [DOI: 10.1111/ijd.16247] [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: 02/22/2022] [Revised: 04/01/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Lawrence E. Gibson
- Departments of Dermatology and Laboratory Medicine and Pathology Mayo Clinic Rochester MN USA
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7
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Shakshouk H, Gibson LE. Pyoderma Gangrenosum-like Skin Ulceration in ANCA-associated vasculitis: A Retrospective Case Series. Clin Exp Dermatol 2022; 47:1716-1719. [PMID: 35524738 DOI: 10.1111/ced.15251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/28/2022]
Abstract
ANCA-associated vasculitis (AAV) can be associated with various cutaneous manifestations. Several case reports have described skin ulceration resembling pyoderma gangrenosum (PG), particularly in granulomatosis with polyangiitis (GPA), however, the true incidence is unknown. In addition, PG is frequently misdiagnosed, and diagnosis may rely on exclusion of other causes of ulcers. We aimed to describe clinical and histopathological features of PG-like ulcerations that occur in association with AAV and illustrate clues to differentiate these ulcers from PG. Retrospective search was conducted to include patients with AAV presenting with PG-like ulcers treated at our institution. This large case series highlights presentation of PG-like ulcers occurring in patients with AAV. Care should be taken to avoid delayed or missed diagnosis of AAV. Distinction between AAV and PG is challenging yet mandatory for proper treatment. Diagnosis relies on a constellation of detailed cutaneous clinical examination, systemic symptoms or illness, histopathological features and laboratory tests.
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Affiliation(s)
| | - Lawrence E Gibson
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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8
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Austin K, Janagan S, Wells M, Crawshaw H, McAdoo S, Robson JC. ANCA Associated Vasculitis Subtypes: Recent Insights and Future Perspectives. J Inflamm Res 2022; 15:2567-2582. [PMID: 35479831 PMCID: PMC9037725 DOI: 10.2147/jir.s284768] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/04/2022] [Indexed: 12/19/2022] Open
Abstract
The ANCA associated vasculitides (AAVs) affect a range of internal organs including ear nose and throat, respiratory tract, kidneys, skin and nervous system. They include granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA) and microscopic polyangiitis (MPA). The AAVs are treated with high dose glucocorticoids, immunosuppressants, and targeted biological medications. Since the 1990s classification criteria for the AAVs have been based on clinical features, laboratory tests and basic imaging; an initiative to update the classification criteria incorporating newer tests, for example, anti-neutrophil cytoplasmic antibodies (ANCA) and novel imaging techniques will be published this year. There is also evidence for classification of patients based on ANCA subtype; those with anti-proteinase 3 antibodies (PR3) or anti-myeloperoxidase antibodies (MPO) have differences in response to treatment and clinical outcomes. An update is described within this review. The pathogenesis of AAV involves necrotizing inflammation of small to medium blood vessels involving multiple immunological pathways. We present an update on emerging evidence related to auto-antibodies, complement and lymphocyte pathways. This review describes emerging treatment regimens, including evidence for plasma exchange in severe disease and the inhibitor of the complement C5a receptor (C5aR) inhibitor, Avacopan. Lastly, patient reported outcomes are key secondary outcomes in randomised controlled trials and increasingly clinical practice, we report development in disease specific and glucocorticoid-specific PROs.
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Affiliation(s)
- Keziah Austin
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
- Correspondence: Keziah Austin, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK, Email
| | - Shalini Janagan
- Department of Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Matthew Wells
- Department of Rheumatology, North Bristol NHS Trust, Bristol, UK
| | - Helena Crawshaw
- Department of Rheumatology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Stephen McAdoo
- Department of Medicine, Imperial College London, London, UK
| | - Joanna C Robson
- Department of Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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9
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Miyabe C, Dong Y, Ikeda T, Takahashi K, Miyabe Y, Kawakami T. Immune checkpoint molecule expression is altered in the skin and peripheral blood in vasculitis. Sci Rep 2021; 11:20019. [PMID: 34625602 PMCID: PMC8501116 DOI: 10.1038/s41598-021-99558-5] [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: 05/17/2021] [Accepted: 09/28/2021] [Indexed: 11/10/2022] Open
Abstract
Dysfunction of immunoinhibitory signals and persistent T cell activation reportedly play important roles in the development of vasculitis. The skin is one of the most accessible organs, and it is suitable for the characterization of immune cell signatures. However, the inhibitory checkpoint molecules in the skin and their relevance to vasculitis have not been studied. Here, we investigated the profile of immune checkpoint molecules in the skin and peripheral blood of patients with vasculitis and healthy donors. We found that some of the inhibitory checkpoint molecules, including programmed cell death 1 receptor (PD-1), were elevated in T-cells in the blood of patients with systemic and cutaneous vasculitis. In addition, programmed death-ligand 1 (PD-L1) expression was elevated in the skin of patients with cutaneous vasculitis. Histologically, PD-L1 was highly expressed in the vessels in the skin along with CD4+ and CD8+ T-cell infiltration in patients with cutaneous vasculitis. Notably, plasma soluble PD-L1 levels were increased, and these correlated with C-reactive protein in patients with systemic vasculitis. Our findings suggest that inhibitory checkpoint molecules might be differentially modulated in the skin and peripheral blood of patients with vasculitis, and that the alteration of the PD-L1/PD-1 axis may be associated with the regulation of T-cell activation in vasculitis.
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Affiliation(s)
- Chie Miyabe
- Division of Dermatology, Tohoku Medical and Pharmaceutical University, Sendai, Japan. .,Department of Dermatology, Tokyo Women's Medical University, Tokyo, Japan.
| | - Yupeng Dong
- Division of Dermatology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Takaharu Ikeda
- Division of Dermatology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kazuo Takahashi
- Division of Dermatology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yoshishige Miyabe
- Department of Cell Biology, Institute for Advanced Medical Sciences, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Tamihiro Kawakami
- Division of Dermatology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
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10
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Frumholtz L, Bouaziz JD, Battistella M, Hadjadj J, Chocron R, Bengoufa D, Le Buanec H, Barnabei L, Meynier S, Schwartz O, Grzelak L, Smith N, Charbit B, Duffy D, Yatim N, Calugareanu A, Philippe A, Guerin CL, Joly B, Siguret V, Jaume L, Bachelez H, Bagot M, Rieux-Laucat F, Maylin S, Legoff J, Delaugerre C, Gendron N, Smadja DM, Cassius C. Type I interferon response and vascular alteration in chilblain-like lesions during the COVID-19 outbreak. Br J Dermatol 2021; 185:1176-1185. [PMID: 34611893 PMCID: PMC8652826 DOI: 10.1111/bjd.20707] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2021] [Indexed: 12/14/2022]
Abstract
Background The outbreak of chilblain‐like lesions (CLL) during the COVID‐19 pandemic has been reported extensively, potentially related to SARS‐CoV‐2 infection, yet its underlying pathophysiology is unclear. Objectives To study skin and blood endothelial and immune system activation in CLL in comparison with healthy controls and seasonal chilblains (SC), defined as cold‐induced sporadic chilblains occurring during 2015 and 2019 with exclusion of chilblain lupus. Methods This observational study was conducted during 9–16 April 2020 at Saint‐Louis Hospital, Paris, France. All patients referred with CLL seen during this period of the COVID‐19 pandemic were included in this study. We excluded patients with a history of chilblains or chilblain lupus. Fifty patients were included. Results Histological patterns were similar and transcriptomic signatures overlapped in both the CLL and SC groups, with type I interferon polarization and a cytotoxic–natural killer gene signature. CLL were characterized by higher IgA tissue deposition and more significant transcriptomic activation of complement and angiogenesis factors compared with SC. We observed in CLL a systemic immune response associated with IgA antineutrophil cytoplasmic antibodies in 73% of patients, and elevated type I interferon blood signature in comparison with healthy controls. Finally, using blood biomarkers related to endothelial dysfunction and activation, and to angiogenesis or endothelial progenitor cell mobilization, we confirmed endothelial dysfunction in CLL. Conclusions Our findings support an activation loop in the skin in CLL associated with endothelial alteration and immune infiltration of cytotoxic and type I IFN‐polarized cells leading to clinical manifestations.
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Affiliation(s)
- L Frumholtz
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France
| | - J-D Bouaziz
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Université de Paris, Human Immunology Pathophysiology Immunotherapy, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France
| | - M Battistella
- Université de Paris, Human Immunology Pathophysiology Immunotherapy, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France.,Pathology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France
| | - J Hadjadj
- Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM U1163, F-75015, Paris, France.,Department of Internal Medicine, National Reference Centre for Rare Systemic Autoimmune Diseases, AP-HP, Hôpital Cochin, F-75014, Paris, France
| | - R Chocron
- Université de Paris, PARCC, INSERM, F-75006, Paris, France.,Emergency Department, AP-HP, Georges Pompidou European Hospital, F-75015, Paris, France
| | - D Bengoufa
- Immunobiology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France
| | - H Le Buanec
- Université de Paris, Human Immunology Pathophysiology Immunotherapy, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France
| | - L Barnabei
- Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM U1163, F-75015, Paris, France
| | - S Meynier
- Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM U1163, F-75015, Paris, France
| | - O Schwartz
- Institut Pasteur, Virus and Immunity Unit, F-75015, Paris, France
| | - L Grzelak
- Institut Pasteur, Virus and Immunity Unit, F-75015, Paris, France
| | - N Smith
- Institut Pasteur, Translational Immunology Lab, F-75015, Paris, France
| | - B Charbit
- Institut Pasteur, Cytometry and Biomarkers UTechS, CRT, F-75015, Paris, France
| | - D Duffy
- Institut Pasteur, Translational Immunology Lab, F-75015, Paris, France.,Institut Pasteur, Cytometry and Biomarkers UTechS, CRT, F-75015, Paris, France
| | - N Yatim
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Institut Pasteur, Translational Immunology Lab, F-75015, Paris, France
| | - A Calugareanu
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Université de Paris, Human Immunology Pathophysiology Immunotherapy, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France
| | - A Philippe
- Institut Pasteur, Cytometry and Biomarkers UTechS, CRT, F-75015, Paris, France
| | - C L Guerin
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, F-75006, Paris, France.,Institut Curie, Cytometry Platform, F-75006, Paris, France
| | - B Joly
- Biological Haematology Department, AP-HP, Hôpital Lariboisière, F-75010, Paris, France.,Université de Paris, EA3518, Institut de Recherche Saint-Louis, F-75010, Paris, France
| | - V Siguret
- Biological Haematology Department, AP-HP, Hôpital Lariboisière, F-75010, Paris, France.,Université de Paris, INSERM UMR S1140, F-75010, Paris, France
| | - L Jaume
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France
| | - H Bachelez
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Université de Paris, Imagine Institute, Laboratory of Genetics of Skin Diseases, INSERM U1163, F-75015, Paris, France
| | - M Bagot
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Université de Paris, Human Immunology Pathophysiology Immunotherapy, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France
| | - F Rieux-Laucat
- Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM U1163, F-75015, Paris, France
| | - S Maylin
- Virology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France
| | - J Legoff
- Virology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Université de Paris, Team Insight, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France
| | - C Delaugerre
- Virology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France
| | - N Gendron
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, F-75006, Paris, France.,Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris-Centre Université de Paris (APHP-CUP), F-75015, Paris, France
| | - D M Smadja
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, F-75006, Paris, France.,Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris-Centre Université de Paris (APHP-CUP), F-75015, Paris, France
| | - C Cassius
- Dermatology Department, AP-HP, Hôpital Saint-Louis, F-75010, Paris, France.,Université de Paris, Human Immunology Pathophysiology Immunotherapy, INSERM U976, Institut de Recherche Saint-Louis, F-75010, Paris, France
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11
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Sone M, Miyabe C, Miyata R, Takenaka Y, Ishiguro N. Relevance of cutaneous manifestations and antineutrophil cytoplasmic antibody status in eosinophilic granulomatosis with polyangiitis. JOURNAL OF CUTANEOUS IMMUNOLOGY AND ALLERGY 2021. [DOI: 10.1002/cia2.12194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Meiko Sone
- Department of Dermatology Tokyo Women's Medical University Tokyo Japan
| | - Chie Miyabe
- Department of Dermatology Tokyo Women's Medical University Tokyo Japan
| | - Ryujin Miyata
- Department of Dermatology Tokyo Women's Medical University Tokyo Japan
| | - Yuko Takenaka
- Department of Dermatology Tokyo Women's Medical University Tokyo Japan
| | - Naoko Ishiguro
- Department of Dermatology Tokyo Women's Medical University Tokyo Japan
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12
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Oz RS, Onajin O, Harel L, Tal R, Dallos T, Rosenblatt A, Plank L, Wagner-Weiner L. Pyoderma gangrenosum-like ulceration as a presenting feature of pediatric granulomatosis with polyangiitis. Pediatr Rheumatol Online J 2021; 19:81. [PMID: 34090470 PMCID: PMC8180159 DOI: 10.1186/s12969-021-00564-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 05/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) is an anti-neutrophilic cytoplasmic antibody-associated vasculitis affecting small to medium-sized vessels and involves most commonly the kidneys and the respiratory tract. Skin involvement can be seen in up to 50% of children with GPA and is the initial presenting symptom in 7.7%. Pyoderma gangrenosum (PG)-like ulcers are rarely described as a skin manifestation in GPA and very few cases have been reported previously in children. CASE PRESENTATION We describe 3 new pediatric cases of GPA with PG-like ulcerations. The median age at first symptom was 15 years. Two patients had PG-like ulceration as their initial presentation; additional symptoms eventually led to the diagnosis of GPA 2-24 months later. In 1 case, proteinase 3 (PR3) was negative when first tested, but converted to positive when systemic symptoms emerged; in the other 2 cases PR3 was positive at presentation. All 3 patients had prominent facial lesions. None of the patients responded to treatment with antibiotics or medications commonly used to manage PG, including corticosteroids and cyclosporine. All patients had excellent responses to rituximab. An electronic database literature review was performed and 4 previously reported cases were identified. We assessed the clinical characteristics, serology, and response to treatment of the previously reported and our newly diagnosed cases. CONCLUSION PG-like ulceration is a rare presentation of pediatric GPA which may precede classic systemic GPA symptoms. The predominance of facial ulcer, granulomatous and neutrophilic inflammation on skin biopsy and lack of response to PG treatments are characteristic of GPA-associated PG-like ulcers. Our review suggests that treatment with rituximab may be needed to improve the skin lesions. Recognizing that PG-like ulcerations can occur in pediatric GPA may result in timely diagnosis, appropriate treatment and improved prognosis.
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Affiliation(s)
- Rotem Semo Oz
- Section of Pediatric Rheumatology, University of Chicago Medical Center, Chicago, IL, USA.
| | - Oluwakemi Onajin
- grid.412578.d0000 0000 8736 9513Section of Dermatology, Department of Medicine, University of Chicago Medical Center, Chicago, IL USA
| | - Liora Harel
- grid.12136.370000 0004 1937 0546Rheumatology Unit, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Petach-Tikva, Israel
| | - Rotem Tal
- grid.12136.370000 0004 1937 0546Rheumatology Unit, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Petach-Tikva, Israel
| | - Tomas Dallos
- grid.7634.60000000109409708Department of Pediatrics, Comenius University Medical Faculty in Bratislava and National Institute of Children’s Diseases, Bratislava, Slovakia
| | - Adena Rosenblatt
- grid.170205.10000 0004 1936 7822Section of Dermatology and Department of Pediatric, University of Chicago, Chicago, USA
| | - Lukas Plank
- grid.449102.aDepartment of Pathology, Comenius University Jessenius Medical Faculty and University Hospital, Martin, Slovakia
| | - Linda Wagner-Weiner
- grid.412578.d0000 0000 8736 9513Section of Pediatric Rheumatology, University of Chicago Medical Center, Chicago, IL USA
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13
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He P, Hu JP, Tian XJ, He LJ, Sun SR, Huang C. Prevalence and risk factors of relapse in patients with ANCA-associated vasculitis receiving cyclophosphamide induction: a systematic review and meta-analysis of large observational studies. Rheumatology (Oxford) 2021; 60:1067-1079. [PMID: 33677596 DOI: 10.1093/rheumatology/keaa667] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/22/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Clinical relapses are common in patients with ANCA-associated vasculitis (AAV). The aim of this systematic review was to estimate time-point prevalence and risk factors of relapse. METHODS We searched PubMed, Embase, and Cochrane Library databases from their inception to March 30, 2020. Cohorts and post-hoc studies were included for the estimation of summary cumulative relapse rates (CRRs) and adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Sensitivity and meta-regression analyses were also performed. RESULTS Of the 42 eligible studies, 24 studies with 6236 participants were used for the pooled analyses of CRRs. The summary 1-year, 3-year, and 5-year CRRs were 0.12 (95% CI, 0.10-0.14), 0.33 (0.29-0.38), and 0.47 (0.42-0.52), respectively. In meta-regressions, the baseline age was positively associated with 1-year CRR. The proportion of granulomatosis with polyangiitis was positively associated with 5-year CRR. Twenty-eight studies with 5390 participants were used for the meta-analysis of risk factors for relapse, including a lower level of baseline serum creatine, proteinase 3 (PR3)-ANCA positivity at diagnosis, an ANCA rise, extrarenal organ involvement (including lung, cardiovascular, upper respiratory, and gastrointestinal involvement), intravenous (vs oral) cyclophosphamide induction, a shorter course of immunosuppressant maintenance, and maintenance with mycophenolate mofetil (vs azathioprine). CONCLUSIONS Our systematic review demonstrated that the 1-year, 3-year, and 5-year cumulative probabilities of relapse were ∼12%, 33%, and 47% in AAV patients receiving cyclophosphamide induction, respectively. Early identification of risk factors for relapse is helpful to the risk stratification of patients so as to achieve personalized treatment.
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Affiliation(s)
- Peng He
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jin-Ping Hu
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiu-Juan Tian
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Li-Jie He
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shi-Ren Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Chen Huang
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
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Fotis L, Prountzos S, Giannouli G, Papaevangelou V. Facial necrotic ulcerative lesions in an adolescent female with granulomatosis with polyangiitis (GPA). Clin Rheumatol 2020; 39:3519-3520. [DOI: 10.1007/s10067-020-05264-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/21/2020] [Accepted: 06/23/2020] [Indexed: 11/24/2022]
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15
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Micheletti RG, Chiesa Fuxench Z, Craven A, Watts RA, Luqmani RA, Merkel PA. Cutaneous Manifestations of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Rheumatol 2020; 72:1741-1747. [PMID: 32419292 DOI: 10.1002/art.41310] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 05/05/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Cutaneous manifestations of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA), are poorly characterized. This report describes the dermatologic features of AAV and their association with systemic manifestations of vasculitis. METHODS A cross-sectional study identifying and comparing the cutaneous manifestations of AAV was performed using data from a large, international, collaborative effort in order to collect comprehensive clinical data on patients with vasculitis. RESULTS Data from 1,184 patients with AAV from 130 centers worldwide were available. Cutaneous manifestations were common in all AAV subtypes: GPA (223 of 656, or 34%), MPA (85 of 302, or 28%), and EGPA (106 of 226, or 47%). The most frequent cutaneous manifestation in AAV (all types) was petechiae/purpura, which was observed in 181 patients (15%). Allergic and nonspecific manifestations, such as pruritus, urticaria, and maculopapular rash, were more common in EGPA than in other disease subtypes (all P < 0.01). Skin biopsy, while underutilized (performed in 22-44% of patients), was frequently found to be an effective test suitable for diagnosis of AAV (diagnostic in 68-94% of patients). Compared to patients without cutaneous manifestations, those with skin lesions more frequently had severe systemic manifestations of vasculitis (such as alveolar hemorrhage and glomerulonephritis), specifically patients with GPA or EGPA and cytoplasmic/anti-proteinase 3 (anti-PR3) ANCA-positive or ANCA-negative patients (hazard ratio >1.9 for all), but not those with MPA or perinuclear/antimyeloperoxidase ANCAs. CONCLUSION Cutaneous manifestations are common and varied in AAV and are associated with disease severity in patients with GPA, EGPA, cytoplasmic/anti-PR3 ANCA, or ANCA-negative disease. These findings underscore the potential diagnostic and prognostic importance of the cutaneous examination in the evaluation and management of AAV.
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Affiliation(s)
| | | | | | - Richard A Watts
- University of Oxford, Oxford, and Norwich Medical School, University of East Anglia, Norwich, UK
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16
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Aitmehdi R, Moguelet P, Godot S, Chazerain P, Senet P, Barbaud A, Frances C, Chasset F. Response to rituximab of pseudotumoral digital nodules in a patient with granulomatosis with polyangiitis with alpha‐1 antitrypsin deficiency: A case report. Dermatol Ther 2020; 33:e13479. [DOI: 10.1111/dth.13479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/07/2020] [Accepted: 04/23/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Raphaël Aitmehdi
- Faculté de Médecine Sorbonne Université AP‐HP, Service de Dermatologie et Allergologie, Hôpital Tenon Paris France
| | - Philippe Moguelet
- Faculté de Médecine Sorbonne Université AP‐HP, Service de Pathologie, Hôpital Tenon Paris France
| | - Sophie Godot
- Service de Rhumatologie Groupe Hospitalier Diaconnesses Croix Saint Simon Paris France
| | - Pascal Chazerain
- Service de Rhumatologie Groupe Hospitalier Diaconnesses Croix Saint Simon Paris France
| | - Patricia Senet
- Faculté de Médecine Sorbonne Université AP‐HP, Service de Dermatologie et Allergologie, Hôpital Tenon Paris France
| | - Annick Barbaud
- Faculté de Médecine Sorbonne Université AP‐HP, Service de Dermatologie et Allergologie, Hôpital Tenon Paris France
| | - Camille Frances
- Faculté de Médecine Sorbonne Université AP‐HP, Service de Dermatologie et Allergologie, Hôpital Tenon Paris France
| | - François Chasset
- Faculté de Médecine Sorbonne Université AP‐HP, Service de Dermatologie et Allergologie, Hôpital Tenon Paris France
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Frumholtz L, Laurent-Roussel S, Lipsker D, Terrier B. Cutaneous Vasculitis: Review on Diagnosis and Clinicopathologic Correlations. Clin Rev Allergy Immunol 2020; 61:181-193. [DOI: 10.1007/s12016-020-08788-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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18
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Colas M, Bentz MH, Raffoul J, Devalland C, Dupond AS. [Atypical purpuric oedema of the nose during granulomatosis with polyangiitis]. Ann Dermatol Venereol 2020; 147:542-546. [PMID: 32305238 DOI: 10.1016/j.annder.2020.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 09/28/2019] [Accepted: 01/28/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Granulomatosis with polyangeitis or Wegener's disease is a necrotizing vasculitis of small and medium vessels associated with antineutrophil cytoplasmic autoantibodies (ANCA). The most frequent sites are lung, ear, nose and throat and kidney. PATIENTS AND METHODS We report the case of a 47-year-old woman presenting purpuric oedematous plaque with bullous detachment of the nose and hospitalised for the assessment of two suspicious neoplastic lung lesions discovered as a result of a recent stroke and repeated seromucosal otitis. Granulomatosis with polyangeitis was suspected because of multiple systemic lesions. The histopathology of skin lesions and laboratory investigation results were consistent with this diagnosis. A favourable outcome was achieved with corticosteroids and rituximab. DISCUSSION The diagnosis of GPA is based on criteria established by the American College of Rheumatology. The cutaneous clinical aspect described in our case confirms the polymorphism of the cutaneous lesions possibly associated with this disease. They are rarely isolated but, in some cases, allow early diagnosis with improved prognosis, which remains severe in the absence of treatment.
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Affiliation(s)
- M Colas
- Service de dermatologie, hôpital Nord Franche Comté (Belfort), 100, route de Moval, 90400 Trévenans, France.
| | - M-H Bentz
- Service de pneumologie, hôpital Nord Franche Comté (Belfort), 100, route de Moval, 90400 Trévenans, France
| | - J Raffoul
- Service d'anatomopathologie, Hôpital Nord Franche Comté (Belfort), 100, route de Moval, 90400 Trévenans, France
| | - C Devalland
- Service d'anatomopathologie, Hôpital Nord Franche Comté (Belfort), 100, route de Moval, 90400 Trévenans, France
| | - A-S Dupond
- Service de dermatologie, hôpital Nord Franche Comté (Belfort), 100, route de Moval, 90400 Trévenans, France
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Berti A, Bond M, Volpe A, Felicetti M, Bortolotti R, Paolazzi G. Practical approach to vasculitides in adults: an overview of clinical conditions that can mimic vasculitides closely. ACTA ACUST UNITED AC 2020. [DOI: 10.4081/br.2020.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Primary systemic vasculitides are rare diseases affecting blood vessel walls. The type and patterns of distribution of the organs affected usually reflect the size of the vessels predominantly involved, and the patterns of clinical manifestations are generally useful to reach a specific diagnosis. However, presenting symptoms may lack adequate specificity for a prompt diagnosis, leading to a diagnostic (and therapeutic) delay, often causing irreversible damage to the affected organs. Due to their rarity and variable clinical presentation, the diagnosis of primary vasculitides could be challenging for physicians. Vasculitis mimickers, i.e. the clinical conditions that could be likely mistaken for vasculitides, need to be carefully ruled out, especially before starting the immunosuppressive therapy. We present here a practical approach to the diagnosis of primary systemic vasculitides involving large, medium and small size vessels, and reviewed most of the conditions that could mimic primary systemic vasculitides.
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20
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Retiform purpura: A diagnostic approach. J Am Acad Dermatol 2020; 82:783-796. [DOI: 10.1016/j.jaad.2019.07.112] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/15/2019] [Accepted: 07/28/2019] [Indexed: 12/28/2022]
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21
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Jarrot PA, Pelletier ML, Brun M, Penicaud M, Mazodier K, Benyamine A, Grande JD, Jean R, Casanova D, Kaplanski G, Weiller PJ. Bilateral Breast Ulcers: Granulomatosis with Polyangiitis. Am J Med 2019; 132:179-181. [PMID: 30240685 DOI: 10.1016/j.amjmed.2018.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/04/2018] [Accepted: 09/04/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Pierre-André Jarrot
- Service de Médecine Interne et d'Immunologie Clinique, CHU Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France.
| | | | - Marion Brun
- Service de Médecine Interne et d'Immunologie Clinique, CHU Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Martin Penicaud
- Service de chirurgie ORL, CHU Conception, AP-HM, Marseille, France
| | - Karin Mazodier
- Service de Médecine Interne et d'Immunologie Clinique, CHU Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | | | - Jean Del Grande
- Laboratoire d'Anatomopathologie, CHU Timone AP-HM, Marseille, France
| | - Rodolphe Jean
- Service de Médecine Interne et d'Immunologie Clinique, CHU Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Dominique Casanova
- Service de Chirurgie Plastique, CHU Conception, AP-HM, Marseille, France
| | - Gilles Kaplanski
- Service de Médecine Interne et d'Immunologie Clinique, CHU Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
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Papi M, Papi C. Biologics in Microangiopathic Wounds. INT J LOW EXTR WOUND 2018. [DOI: 10.1177/1534734618813767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the last decades the possibility to diagnose a skin ulcer has greatly improved. We learnt that a consistent percentage of nonhealing ulcers may be caused by a microangiopathic disorder that has not been properly investigated and cured. Pathogenetically, we can distinguish 2 main groups: (1) ulcers due to inflammatory microangiopathy, mainly including cutaneous small and medium vessel vasculitis, pyoderma gangrenosum, and connective tissue diseases, and (2) ulcers due to occlusive microangiopathy. The group of microangiopathic occlusive ulcers is more heterogeneous and includes different disorders ranging from livedo vasculopathy to calciphylaxis, hydroxyurea-induced ulcers, antiphospholipid antibodies ulcers, and various other types. These conditions can induce thromboses or anatomo-functional occlusion of cutaneous microvessels. Despite different physiopathologic mechanisms, the ulcer resulting from a primitive microangiopathy may receive basic treatments that are in the complex similar to other pathogenetically different wounds, including MOIST-based local therapy and elastic compression when it is not contraindicated. Persistent inflammatory processes are increasingly demonstrated as responsible for the chronicity of many skin ulcers. New data concerning the biological phases of wound healing and the molecules that play crucial roles in this process suggested the use of new specific therapies. Some of them such as growth factors and platelet-rich plasma are prevalently used as topical biologic agents with variable benefits. In recent years, a new class of systemic anti-inflammatory molecules, better known as biologic drugs, have been introduced in the cure of chronic inflammatory diseases that can induce microangiopathic injuries and ulcerative complication. They enlarged the therapeutic options in case of nonresponder microangiopathic ulcers and could represent a future model of “pathogenetically based” therapy of skin ulcers.
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Affiliation(s)
- Massimo Papi
- National Institute of Health, Migration and Poverty, Rome, Italy
| | - Claudia Papi
- Catholic University Policlinico A. Gemelli, Rome, Italy
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24
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Pyoderma gangrenosum-like ulcerations in granulomatosis with polyangiitis: two cases and literature review. Rheumatol Int 2018; 38:1139-1151. [PMID: 29721696 DOI: 10.1007/s00296-018-4035-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 04/26/2018] [Indexed: 12/16/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a systemic necrotizing small vessel vasculitis associated with circulating anti-neutrophil cytoplasmic antibodies (ANCAs). Skin manifestations, mostly represented by palpable purpura, papulonodular lesions and livedo reticularis, are present in up to 50% of the cases. Ulcerations with undermined, raised erythematous-violaceous border resembling pyoderma gangrenosum (PG) have rarely been reported as skin involvement in GPA. The presence of circulating ANCAs with a cytoplasmic labelling pattern, the involvement of internal organs, particularly of the lung, and the absence on histology of a mainly neutrophilic infiltrate in early phases of the cutaneous lesions may be regarded as clues to rule out true PG and confirm the diagnosis of GPA skin ulcerations simulating PG. Herein, we describe two paradigmatic cases of such a unique presentation of GPA and a literature review focusing on clinicopathological features of GPA presenting with PG-like ulcerations in the skin has been provided. Moreover, referring to the scenario observed in these two cases, an easy-to-use working approach for the differential diagnosis between the two conditions has also been proposed.
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Kishore S, Mittal V, Ahuja S, Majithia V. When a wound is the harbinger of a serious underlying systemic illness. BMJ Case Rep 2018; 2018:bcr-2017-222491. [PMID: 29386209 DOI: 10.1136/bcr-2017-222491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 55-year-old woman presented with progressive enlarging and painful non-healing ulcers on her bilateral lower extremities; biopsy was consistent with pyoderma gangrenosum. Workup for an underlying illness revealed a cavitary lung nodule and an ulcerating mass in the anal canal. Patient did not have any respiratory or gastrointestinal symptoms. Differential diagnosis included inflammatory bowel disease, rectal carcinoma or infection such as tuberculosis, fungal process. Histopathology did not reveal any malignancy, inflammatory bowel disease or infection. Serological studies were positive for perinuclear antineutrophil antibodies specific to proteinase-3 antigen, and the patient was ultimately diagnosed with granulomatosis with polyangiitis. Intravenous pulse dose steroids were initiated followed by monthly pulse cyclophosphamide for 6 months, resulting in rapid and significant improvement of the wounds.
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Affiliation(s)
- Shweta Kishore
- Department of Rheumatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Varun Mittal
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Shradha Ahuja
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Vikas Majithia
- Department of Rheumatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
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