1
|
Norimatsu Y, Saku A, Kawashima H, Minagawa T, Itano O, Shiga T, Hayashi Y, Hirose K, Sugaya M. Polyarteritis nodosa with splenic rupture and multiple cerebral infarctions. J Dermatol 2024; 51:e259-e260. [PMID: 38414162 DOI: 10.1111/1346-8138.17162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Yuta Norimatsu
- Department of Dermatology, International University of Health and Welfare, Narita, Chiba, Japan
| | - Aiko Saku
- Department of Allergy and Rheumatology, International University of Health and Welfare, Narita, Chiba, Japan
| | - Hirotoshi Kawashima
- Department of Allergy and Rheumatology, International University of Health and Welfare, Narita, Chiba, Japan
| | - Takuya Minagawa
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Osamu Itano
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Takashi Shiga
- Department of Emergency Medicine, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Yuichiro Hayashi
- Department of Pathology, International University of Health and Welfare, Narita, Chiba, Japan
| | - Koichi Hirose
- Department of Allergy and Rheumatology, International University of Health and Welfare, Narita, Chiba, Japan
| | - Makoto Sugaya
- Department of Dermatology, International University of Health and Welfare, Narita, Chiba, Japan
| |
Collapse
|
2
|
Shimojima Y, Nomura S, Ushiyama S, Ichikawa T, Takamatsu R, Kishida D, Sekijima Y. Early skeletal muscle manifestations in polyarteritis nodosa and ANCA-associated vasculitis. Autoimmun Rev 2024; 23:103602. [PMID: 39153646 DOI: 10.1016/j.autrev.2024.103602] [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: 04/01/2024] [Revised: 08/03/2024] [Accepted: 08/14/2024] [Indexed: 08/19/2024]
Abstract
Skeletal muscle involvement is common in patients with small- and medium-sized vasculitis, particularly polyarteritis nodosa (PAN) and antineutrophil cytoplasmic antibody-associated vasculitis (AAV). Despite being not included in the standard classification criteria for PAN and AAV, skeletal muscle involvement is an important clinical indicator, particularly when vasculitic myopathy is the only pathological evidence in the absence of other organ involvement. Herein, we comprehensively reviewed and compared the clinical features of 71 and 135 patients with PAN and AAV, respectively, with skeletal muscle involvement at the time of disease onset. Most patients with PAN and AAV exhibited skeletal muscle involvement, often characterized by myalgia and occasional muscular weakness, predominantly in the lower extremities. Myalgia and weakness were observed more frequently in the distal lower extremities in patients with PAN than in those with AAV. In contrast, skeletal muscle involvement tended to exhibit a more dispersed distribution across all four extremities in those with AAV. Muscle magnetic resonance imaging T2-weighted and short-tau inversion recovery sequences can effectively identify hyperintense areas attributed to hypervascularity of affected muscle tissues and serve as a sensitive and useful modality for visually determining the suitable biopsy site. >90% of patients with PAN and AAV demonstrated perivascular inflammation in their affected muscle tissues, whereas fibrinoid necrosis of the vessel walls was reported in two-thirds of patients. Serum creatine kinase (CK) levels were within the normal range in approximately 80% of patients presenting with skeletal muscle involvement in PAN and AAV. Furthermore, muscle fiber damage was milder in patients with skeletal muscle involvement in PAN and AAV than those with idiopathic inflammatory myositis. Meanwhile, serum CK levels were elevated in 65-85% of patients with PAN and AAV who had myofiber necrosis and degeneration in the affected muscles. Most patients with PAN and AAV showed improvement in skeletal muscle involvement following glucocorticoids (GCs) administration; however, relapse was observed in some patients during the tapering of GCs. In summary, skeletal muscle involvement is a potential indicator for establishing PAN and AAV diagnoses during the early phases of the disease.
Collapse
Affiliation(s)
- Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.
| | - Shun Nomura
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoru Ushiyama
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Takanori Ichikawa
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryota Takamatsu
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Dai Kishida
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| |
Collapse
|
3
|
Kidder D, Basu N. The Extinction of Primary Polyarteritis Nodosa: A Modern Science Success Story? Arthritis Rheumatol 2024; 76:996-998. [PMID: 38556926 DOI: 10.1002/art.42851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/11/2024] [Accepted: 03/25/2024] [Indexed: 04/02/2024]
Affiliation(s)
- Dana Kidder
- University of Aberdeen, Aberdeen, United Kingdom
| | - Neil Basu
- University of Glasgow, Glasgow, United Kingdom
| |
Collapse
|
4
|
González-Gay MÁ, Heras-Recuero E, Blázquez-Sánchez T, Caraballo-Salazar C, Rengifo-García F, Castañeda S, Martín J, Marquez A, Largo R. Genetics of vasculitis. Best Pract Res Clin Rheumatol 2024:101969. [PMID: 38955656 DOI: 10.1016/j.berh.2024.101969] [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: 03/21/2024] [Revised: 06/16/2024] [Accepted: 06/24/2024] [Indexed: 07/04/2024]
Abstract
Systemic vasculitis encompasses a wide range of conditions characterized by varying degrees of inflammation in blood vessels. Although the etiology of vasculitis remains unclear, accumulated data suggest that it is triggered in genetically predisposed individuals by the concurrence of certain environmental factors. The importance of the genetic component has been consistently supported by evidence of familial aggregation, differential prevalence by ethnicity, and multiple genetic associations with disease susceptibility and severity reported in recent years. The strongest association signals in most vasculitides correspond to genetic variants within the HLA region, suggesting an important role of the immune system in its pathophysiology. However, each type of vasculitis has distinct defining HLA association markers, likely due to disease-specific differences in antigenic drivers. Furthermore, other genetic polymorphisms located outside the HLA region play an important role in susceptibility to different vasculitides. More recent research has assessed the shared genetic susceptibility evident across different vasculitides. Future studies should focus on the identification of genetic markers that can serve as reliable biomarkers for early diagnosis, prognosis, and treatment response in systemic vasculitis.
Collapse
Affiliation(s)
- Miguel Ángel González-Gay
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain; Medicine and Psychiatry Department, University of Cantabria, Santander, Spain.
| | | | | | | | | | - Santos Castañeda
- Division of Rheumatology, Hospital Universitario de La Princesa, IIS-Princesa, Madrid, Spain.
| | - Javier Martín
- Institute of Parasitology and Biomedicine López-Neyra. Consejo Superior de Investigaciones Científicas (IPBLN-CSIC), Granada, Spain.
| | - Ana Marquez
- Institute of Parasitology and Biomedicine López-Neyra. Consejo Superior de Investigaciones Científicas (IPBLN-CSIC), Granada, Spain.
| | - Raquel Largo
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain.
| |
Collapse
|
5
|
Verigou EA, Skajaa N, Tanwar H. Spontaneous hepatic artery pseudoaneurysm rupture as a first presentation of polyarteritis nodosa. BMJ Case Rep 2024; 17:e257411. [PMID: 38937262 DOI: 10.1136/bcr-2023-257411] [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: 06/29/2024] Open
Abstract
A man in his 70s presented with a sudden onset stabbing back pain radiating to the chest and pre-syncopal symptoms. He underwent urgent investigations, including a CT angiogram aorta which did not reveal any abnormalities within the thorax, abdomen or pelvis and no cause of symptoms was identified. After being discharged, he re-presented 2 days later with syncopal episodes, abdominal pain and a significant drop in haemoglobin levels. This time, a CT mesenteric angiogram showed two hepatic artery pseudoaneurysms and a large haemoperitoneum. Following a hepatic artery embolisation, a workup showed that the likely cause of the pseudoaneurysms was a rare first presentation of polyarteritis nodosa. This case highlights the importance of considering the possibility of an aneurysmal rupture, especially when common causes of an acute abdomen have been excluded, and not relying on previous negative investigations to exclude pathology, as the outcomes can be detrimental.
Collapse
Affiliation(s)
| | | | - Hitendra Tanwar
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
- Urgent and emergency care [UEC] Acute Medicine, East Kent Hospital University Foundation Trust, Ashford, Kent, UK
| |
Collapse
|
6
|
Tabibi P, Shiari R, Shafiee A, Rahmani K, Saravi N. Case report of streptococcal infection as a potential precipitating factor in cutaneous polyarteritis nodosa in pediatric patients. Clin Case Rep 2024; 12:e9038. [PMID: 38827940 PMCID: PMC11142904 DOI: 10.1002/ccr3.9038] [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: 04/23/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 06/05/2024] Open
Abstract
Key Clinical Message This pediatric case report underscores the importance of maintaining a high clinical suspicion for polyarteritis nodosa (PAN) in patients presenting with atypical features, such as migratory arthritis and subcutaneous nodules. Importantly, it highlights the focus on the potential relationship between streptococcal infection and cutaneous PAN. Early recognition and prompt, aggressive treatment is critical, as PAN can be a life-threatening condition if left unmanaged. This case emphasizes the need for a multidisciplinary approach to effectively identify and manage this rare vasculitis disorder in the pediatric population. Abstract Polyarteritis nodosa (PAN) is a rare and life-threatening vasculitis with diverse clinical presentations, posing a diagnostic challenge. Early recognition and prompt intervention are crucial to prevent organ damage. We present the case of an 8-year-old boy who exhibited atypical symptoms including migratory arthritis, myalgia, digital discoloration and ischemic changes, and subcutaneous nodules. Initial concerns for septic arthritis were ruled out. A comprehensive evaluation revealed elevated inflammatory markers and a confirmatory skin biopsy demonstrating active leukocytoclastic vasculitis, are highly suggestive of a diagnosis of PAN. Notably, elevated ASO titers suggested a possible concurrent streptococcal infection. The aggressive treatment approach with high-dose aspirin, steroids, methotrexate, and tocilizumab is justified given the severity of the patient's symptoms and the nature of the disease process. This case underscores the importance of considering PAN in the differential diagnosis for children presenting with atypical features. Early diagnosis and prompt intervention, including addressing potential infectious triggers, are crucial for optimal outcomes in pediatric PAN.
Collapse
Affiliation(s)
- Pooneh Tabibi
- Department of PediatricsMofid Children's Hospital, Shahid Beheshti University of Medical SciencesTehranIran
| | - Reza Shiari
- Department of PediatricsMofid Children's Hospital, Shahid Beheshti University of Medical SciencesTehranIran
| | - Ali Shafiee
- Department of PediatricsMofid Children's Hospital, Shahid Beheshti University of Medical SciencesTehranIran
| | - Khosro Rahmani
- Department of PediatricsMofid Children's Hospital, Shahid Beheshti University of Medical SciencesTehranIran
| | - Niloofar Saravi
- Department of PediatricsMofid Children's Hospital, Shahid Beheshti University of Medical SciencesTehranIran
| |
Collapse
|
7
|
Ruffer N, Krusche M, Holl-Ulrich K, Lötscher F, Kötter I. [Hughes-Stovin syndrome: a life-threatening manifestation of Behçet's syndrome]. Z Rheumatol 2024; 83:327-333. [PMID: 37280333 PMCID: PMC11058631 DOI: 10.1007/s00393-023-01371-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/08/2023]
Abstract
Hughes-Stovin syndrome (HSS) is a systemic inflammatory condition of unknown origin that is considered to be part of the Behçet's syndrome (BS) spectrum. Recurrent venous thrombosis and superficial thrombophlebitis in combination with bilateral pulmonary artery aneurysms (PAA) represent the hallmark of HSS. The diagnostic evaluation includes computed tomography pulmonary angiography to detect signs of pulmonary vasculitis. The management of HSS is based on the European Alliance of Associations for Rheumatology (EULAR) recommendations for BS and mainly comprises immunosuppressive therapy with glucocorticoids and cyclophosphamide. In addition to drug therapy, PAA should be evaluated for interventional treatment. Spontaneous PAA rupture due to fragile vessel architecture can occur even in cases of remission and/or PAA regression.
Collapse
Affiliation(s)
- Nikolas Ruffer
- III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Martin Krusche
- III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Konstanze Holl-Ulrich
- Konsultations- und Referenzzentrum für Vaskulitis-Diagnostik, Labor Lademannbogen MVZ GmbH, Hamburg, Deutschland
| | - Fabian Lötscher
- Universitätsklinik für Rheumatologie und Immunologie, Inselspital, Universitätsspital Bern, Bern, Schweiz
| | - Ina Kötter
- III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| |
Collapse
|
8
|
Di Florio DN, Beetler DJ, McCabe EJ, Sin J, Ikezu T, Fairweather D. Mitochondrial extracellular vesicles, autoimmunity and myocarditis. Front Immunol 2024; 15:1374796. [PMID: 38550582 PMCID: PMC10972887 DOI: 10.3389/fimmu.2024.1374796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/28/2024] [Indexed: 04/02/2024] Open
Abstract
For many decades viral infections have been suspected as 'triggers' of autoimmune disease, but mechanisms for how this could occur have been difficult to establish. Recent studies have shown that viral infections that are commonly associated with viral myocarditis and other autoimmune diseases such as coxsackievirus B3 (CVB3) and SARS-CoV-2 target mitochondria and are released from cells in mitochondrial vesicles that are able to activate the innate immune response. Studies have shown that Toll-like receptor (TLR)4 and the inflammasome pathway are activated by mitochondrial components. Autoreactivity against cardiac myosin and heart-specific immune responses that occur after infection with viruses where the heart is not the primary site of infection (e.g., CVB3, SARS-CoV-2) may occur because the heart has the highest density of mitochondria in the body. Evidence exists for autoantibodies against mitochondrial antigens in patients with myocarditis and dilated cardiomyopathy. Defects in tolerance mechanisms like autoimmune regulator gene (AIRE) may further increase the likelihood of autoreactivity against mitochondrial antigens leading to autoimmune disease. The focus of this review is to summarize current literature regarding the role of viral infection in the production of extracellular vesicles containing mitochondria and virus and the development of myocarditis.
Collapse
Affiliation(s)
- Damian N. Di Florio
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, United States
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN, United States
| | - Danielle J. Beetler
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, United States
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN, United States
| | - Elizabeth J. McCabe
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Jon Sin
- Department of Biological Sciences, University of Alabama, Tuscaloosa, AL, United States
| | - Tsuneya Ikezu
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, United States
| | - DeLisa Fairweather
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, United States
- Department of Immunology, Mayo Clinic, Jacksonville, FL, United States
- Department of Medicine, Mayo Clinic, Jacksonville, FL, United States
| |
Collapse
|
9
|
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.
Collapse
Affiliation(s)
- Manish K Saha
- Division of Nephrology, University of North Carolina, Chapel Hill, NC, USA.
| |
Collapse
|
10
|
Suzuki K, Akiyama M, Kondo Y, Saito S, Kikuchi J, Hanaoka H, Kaneko Y. Re-emphasising the importance of catheter-based angiography to differentiate polyarteritis nodosa from cutaneous arteritis: Two case reports. Mod Rheumatol Case Rep 2023; 8:133-136. [PMID: 37947049 DOI: 10.1093/mrcr/rxad064] [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: 08/29/2023] [Revised: 10/14/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
Polyarteritis nodosa (PAN) is a systemic necrotising vasculitis with a poor prognosis, characterised by inflammation and necrosis of medium-sized arteries. PAN patients can present with a wide range of systemic manifestations, whereas cutaneous arteritis (CA) is a restricted manifestation to skin of the disease with a more favourable prognosis. Thus, differentiation between PAN and CA is crucial. Here, we present two cases that were initially diagnosed as CA due to the limited presence of systemic symptoms, but were finally diagnosed as PAN through catheter-based angiography. Although contrast-enhanced computed tomography and computed tomographic angiography are increasingly used to diagnose PAN, neither case had any abnormal findings on these examinations. Our cases therefore underscore that catheter-based angiography is critical for differentiation between PAN and CA, even in cases with limited systemic symptoms.
Collapse
Affiliation(s)
- Koji Suzuki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuhiro Akiyama
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Kondo
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shuntaro Saito
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Jun Kikuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hironari Hanaoka
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
11
|
Abuhammad A, Dukmak ON, Asad D, Bakri IA, Attawna SIY. Polyarteritis nodosa in a patient with chronic hepatitis B following COVID-19 vaccination: a case report. Oxf Med Case Reports 2023; 2023:omad092. [PMID: 37771685 PMCID: PMC10530314 DOI: 10.1093/omcr/omad092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/10/2023] [Accepted: 08/02/2023] [Indexed: 09/30/2023] Open
Abstract
Different types of vasculitis have been reported after various vaccine administrations. Recently, the coronavirus disease 2019 (COVID-19) vaccine was one of the most common vaccine-induced vasculitis. Herein, we describe a 56-year-old male patient with chronic hepatitis B who presented with abdominal pain for 2 days, which was associated with vomiting and bloody diarrhea. He had a history of petechial rash for 25 days, multiple joint pain and lower limb weakness after the second dose of the COVID-19 vaccine. A skin biopsy showed medium-sized vessel vasculitis. Polyarteritis nodosa (PAN) was diagnosed depending on the American College of Rheumatology criteria. He was treated with steroids, plasmapheresis and antiviral medication with a good prognosis. In patients with a past medical history of chronic hepatitis B, the covid vaccine may be associated with an increased risk of developing a PAN, so clinicians should suspect the occurrence of this disease after COVID-19 vaccination.
Collapse
Affiliation(s)
- Aseel Abuhammad
- Al-Quds University Faculty of Medicine, Jerusalem, State of Palestine
| | - Osama N Dukmak
- Al-Quds University Faculty of Medicine, Jerusalem, State of Palestine
| | - Diya Asad
- Al-Quds University Faculty of Medicine, Jerusalem, State of Palestine
| | | | | |
Collapse
|
12
|
Vats V, Patel K, Sharma DD, Almansouri NE, Makkapati NSR, Nimal S, Ramteke P, Mohammed Arifuddin B, Jagarlamudi NS, Narain A, Raut YD. Exploring Cardiovascular Manifestations in Vasculitides: An In-Depth Review. Cureus 2023; 15:e44417. [PMID: 37791229 PMCID: PMC10543473 DOI: 10.7759/cureus.44417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 10/05/2023] Open
Abstract
Systemic vasculitides encompass a cluster of autoimmune diseases that affect blood vessels, and are characterized by immune-mediated injury to either small- or large-sized blood vessels. Individuals afflicted with systemic vasculitides experience notable morbidity and mortality attributable to cardiovascular manifestations. Noteworthy among these are ischemic heart disease, venous thromboembolism, aortic involvement, valvular irregularities, myocarditis, and pericarditis. This narrative review investigated and evaluated the prevalent cardiovascular disturbances commonly associated with different types of vasculitides. This review also discusses the mechanisms that underlie these manifestations. It also provides a thorough explanation of the many diagnostic techniques essential for detecting the disease at its occult stage. It is essential for healthcare professionals to have knowledge of the cardiovascular complications caused by vasculitides, as this enables them to promptly recognize these symptoms and employ suitable diagnostic techniques early on. By doing so, timely detection can be ensured, which will subsequently aid in initiating appropriate treatment strategies that are vital for decreasing morbidity and mortality in patients with systemic vasculitides.
Collapse
Affiliation(s)
- Vaibhav Vats
- Internal Medicine, Smt. Kashibai Navale Medical College and General Hospital, Mumbai, IND
| | - Kriyesha Patel
- Internal Medicine, MP Shah Medical College, Jamnagar, IND
| | | | | | | | - Simran Nimal
- Internal Medicine, Byramjee Jeejeebhoy (BJ) Government Medical College, Pune, IND
| | - Palash Ramteke
- Medical School, NKP Salve Institute of Medical Sciences, Nagpur, IND
| | | | | | - Archit Narain
- Internal Medicine, Lala Lajpat Rai Memorial Medical College, Meerut, IND
| | - Yogesh D Raut
- Miscellaneous, NKP Salve Institute of Medical Sciences, Nagpur, IND
| |
Collapse
|
13
|
Castaneda PR, Luthringer D, Mitra AP. Hemorrhagic Infarct Secondary to Vasculitis Presenting as Testicular Mass. Urology 2023; 178:e197-e198. [PMID: 37301329 DOI: 10.1016/j.urology.2023.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Affiliation(s)
| | - Daniel Luthringer
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Anirban P Mitra
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Department of Computational Biomedicine, Cedars-Sinai Medical Center, Los Angeles, CA.
| |
Collapse
|
14
|
El-Farra MH, Yahia R, Cetinkaya A, Hasaniya N. Intraperitoneal hemorrhage secondary to ruptured omental artery aneurysm associated with polyarteritis nodosa: a case report. Surg Case Rep 2023; 9:94. [PMID: 37266725 DOI: 10.1186/s40792-023-01675-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/19/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Polyarteritis nodsa (PAN) is a rare disease characterized by acute focal inflammatory damage to small and medium arteries. PAN complicated by ruptured aneurysm is an infrequent presentation with the most affected arteries being the renal and mesenteric arteries. CASE PRESENTATION A 76-year-old female presented with a low-grade fever, generalized body aches, and abdominal pain. Investigation revealed intraperitoneal bleeding secondary to a ruptured and actively bleeding right omental artery aneurysm. Clinical manifestation, angiography and histology were consistent with PAN. Laparotomy was performed for stabilization and resection of the bleeding aneurysm followed by post operative steroids and cyclophosphamide. Patient was discharged in a stable condition. We reviewed seven cases found in the literature of omental artery aneurysm and rupture. Four cases were proceeded with laparotomy and aneurysm resection while three cases were proceeded with a less invasive approach of arterial embolization. CONCLUSIONS Omental artery aneurysm is a rare occurrence with even fewer reported cases associated with PAN. Of the seven reported cases, all patients were treated with a surgical intervention. In addition, PAN patients should be treated post-operatively with a course of steroids and cyclophosphamide.
Collapse
Affiliation(s)
- Mohamed H El-Farra
- University of California Riverside School of Medicine, 92521 Botanic Gardens Dr, Riverside, CA, 92507, USA.
| | - Rayan Yahia
- University of California Riverside School of Medicine, 92521 Botanic Gardens Dr, Riverside, CA, 92507, USA
| | | | - Nahidh Hasaniya
- University of California Riverside School of Medicine, 92521 Botanic Gardens Dr, Riverside, CA, 92507, USA
- Department of Surgery, St. Bernardine Medical Center, San Bernardino, CA, USA
| |
Collapse
|
15
|
Fijolek J, Radzikowska E. Eosinophilic granulomatosis with polyangiitis - Advances in pathogenesis, diagnosis, and treatment. Front Med (Lausanne) 2023; 10:1145257. [PMID: 37215720 PMCID: PMC10193253 DOI: 10.3389/fmed.2023.1145257] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/13/2023] [Indexed: 05/24/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare disease characterized by eosinophil-rich granulomatous inflammation and necrotizing vasculitis, pre-dominantly affecting small-to-medium-sized vessels. It is categorized as a primary antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) but also shares features of hypereosinophilic syndrome (HES); therefore, both vessel inflammation and eosinophilic infiltration are suggested to cause organ damage. This dual nature of the disease causes variable clinical presentation. As a result, careful differentiation from mimicking conditions is needed, especially from HES, given the overlapping clinical, radiologic, and histologic features, and biomarker profile. EGPA also remains a diagnostic challenge, in part because of asthma, which may pre-dominate for years, and often requires chronic corticosteroids (CS), which can mask other disease features. The pathogenesis is still not fully understood, however, the interaction between eosinophils and lymphocytes B and T seems to play an important role. Furthermore, the role of ANCA is not clear, and only up to 40% of patients are ANCA-positive. Moreover, two ANCA-dependent clinically and genetically distinct subgroups have been identified. However, a gold standard test for establishing a diagnosis is not available. In practice, the disease is mainly diagnosed based on the clinical symptoms and results of non-invasive tests. The unmet needs include uniform diagnostic criteria and biomarkers to help distinguish EGPA from HESs. Despite its rarity, notable progress has been made in understanding the disease and in its management. A better understanding of the pathophysiology has provided new insights into the pathogenesis and therapeutic targets, which are reflected in novel biological agents. However, there remains an ongoing reliance on corticosteroid therapy. Therefore, there is a significant need for more effective and better-tolerated steroid-sparing treatment schemes.
Collapse
|
16
|
Hankard A, Puéchal X, Martin Silva N, Deshayes S, Lorcy N, Le Gallou T, Carron PL, Daugas E, Kaplanski G, Boutemy J, Maigné G, Galimard C, Terrier B, Aouba A, de Boysson H. Characteristics of ANCA-associated vasculitis with aneurysms: Case series and review of the literature. Autoimmun Rev 2023; 22:103293. [PMID: 36787809 DOI: 10.1016/j.autrev.2023.103293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION ANCA-associated vasculitis (AAV) is an exceptional cause of small and large vascular aneurysms. Here, we present the phenotypic characteristics of patients with AAV associated with the presence of aneurysms. METHODS We conducted a retrospective multicenter study and a systematic review of the literature. Only AAV patients with positive ANCA results and > 1 aneurysm(s) were enrolled. Patients were recruited through a call of observations among the French Vasculitis Study Group (FVSG) and the French Internal Medicine Network. Patients with aneurysm rupture were compared to those without. RESULTS We enrolled 51 patients in the cohort, including 31 (67%) with granulomatosis with polyangiitis. The median Birmingham Vasculitis Activity Score was 18 [6-41]. A total of 92 aneurysms were noted, 74% of which involved medium-sized arteries, particularly the renal artery. During a follow-up of 24 [6-56] months, 22 (43%) patients experienced aneurysmal rupture, 91% of which involved medium-sized vessels. Patients with aneurysmal rupture showed significantly more pulmonary infiltrates and higher creatinine levels at baseline than patients without rupture. Initial treatments did not differ between the two groups. Ten (20%) patients died during the follow-up, including three from an aneurysmal rupture. CONCLUSION Aneurysms were more frequently observed in GPA patients and predominantly affected medium-sized vessels, especially the renal arteries. The risk of rupture was high and occurred in >40% of patients. Because of their increased mortality, further studies are required to better manage this subset of patients.
Collapse
Affiliation(s)
- Antoine Hankard
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France.
| | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Centre, Université Paris Cité, Paris, France
| | - Nicolas Martin Silva
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Samuel Deshayes
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Nolwenn Lorcy
- Department of Nephrology, Rennes University Hospital, Rennes, France
| | - Thomas Le Gallou
- Department of Internal Medicine, Rennes University Hospital, South Hospital, Rennes, France
| | | | - Eric Daugas
- Department of Nephrology, Bichat-Claude-Bernard Hospital, University Hospital Center, APHP, Paris, France
| | - Gilles Kaplanski
- Department of Internal Medicine, La Conception Hospital, University Hospital Center, APHM, Marseille, France
| | - Jonathan Boutemy
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Gwénola Maigné
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Caroline Galimard
- Department of Infectious Disease Medicine, Caen University Hospital, Basse Normandie University, Caen, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Centre, Université Paris Cité, Paris, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France; Université de Caen Normandie, Caen, France
| | - Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital, Basse Normandie University, Caen, France; Université de Caen Normandie, Caen, France
| |
Collapse
|
17
|
Pratap R, Raj G. Leg muscle involvement in polyarteritis nodosa (limited form)-A rare case report. Radiol Case Rep 2023; 18:1601-1604. [PMID: 36852291 PMCID: PMC9958253 DOI: 10.1016/j.radcr.2023.01.079] [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: 11/26/2022] [Revised: 01/22/2023] [Accepted: 01/23/2023] [Indexed: 02/16/2023] Open
Abstract
Polyarteritis nodosa is a necrotizing arteritis involving small and medium vessels. Polyarteritis nodosa can have variable presentations depending upon the organ involved. It can either present as a diffuse disease or a limited form confined to a particular organ. Isolated muscular involvement in this disease is rare, which may present as myalgia, nonspecific fever, weight loss or even as claudication. The imaging pattern on ultrasound and MRI can help diagnose this condition in the background of clinical history and muscle biopsy is confirmatory. We present a case of 15 years old boy who presented with fever, weight loss, myalgia in leg region. MRI and ultrasound examination showed perivascular inflammation in calf muscles with a characteristic "cotton wool" pattern of enhancement on contrast study.
Collapse
Affiliation(s)
- Rishabh Pratap
- Junior Resident, Department of Radiodiagnosis, Dr Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomtinagar, Lucknow 226010, Uttar Pradesh, India,Corresponding author.
| | - Gaurav Raj
- Professor and Head, Department of Radiodiagnosis, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| |
Collapse
|
18
|
van der Geest KS, Slijkhuis BG, Tomelleri A, Gheysens O, Jiemy WF, Piccolo C, Nienhuis P, Sandovici M, Brouwer E, Glaudemans AW, Mulder DJ, Slart RH. Positron Emission Tomography Imaging in Vasculitis. Cardiol Clin 2023; 41:251-265. [PMID: 37003681 DOI: 10.1016/j.ccl.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Systemic vasculitides comprise a group of autoimmune diseases affecting blood vessels. [18F]-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (FDG-PET/CT) plays an important role in the diagnosis and therapeutic monitoring of vasculitides affecting large-sized and medium-sized vessels. FDG-PET/CT also provides complementary information to other vascular imaging tools. The resolution and sensitivity of newer generation scanners continues to increase, hereby improving the ability of FDG-PET/CT to accurately assess the full disease extent in patients with vasculitis. Novel tracers targeting specific immune cells will allow for more detailed detection of vascular infiltrates.
Collapse
|
19
|
Zhao L, Kong X, Zhao J, Zhou J, Zhang S, Xu D, Tian X, Zeng X, Zhang F. Identifying risk and prognostic factors in polyarteritis nodosa patients with digital gangrene. Int J Rheum Dis 2023; 26:236-241. [PMID: 36261880 DOI: 10.1111/1756-185x.14467] [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: 04/21/2022] [Revised: 08/19/2022] [Accepted: 09/19/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many patients with polyarteritis nodosa (PAN) complicated by digital gangrene have poor outcomes and related research information is limited. Our aim is to identify the associated risk and prognostic factors in PAN patients with digital gangrene. PATIENTS AND METHODS We conducted a retrospective study of 148 PAN patients admitted to Peking Union Medical College Hospital from Octorber 2001 to December 2018. Forty-seven (31.8%) PAN patients had digital gangrene. The average age was 40.4 ± 17.9 years. RESULTS The presence of digital gangrene was correlated with current smoking (P = .008, odds ratio [OR] 2.99, 95% CI, 1.33-6.73), eosinophil elevation (P = .003, OR 4.21, 95% CI, 1.62-10.91) and elevated leukocytes (P = .001, OR 4.26, 95% CI, 1.86-9.78). Thirty-two (68.1%) gangrene patients received methylprednisolone pulse therapy and all of these patients were treated with cyclophosphamide. Nine patients suffered irreversible organ injury and 2 died. Survival analysis showed higher serum C-reactive protein (CRP) was associated with poor prognosis in patients with gangrene (log-rank P = 0.042 and generalized Wilcoxon P = .020). CONCLUSIONS PAN patients with current smoking and eosinophil elevation were more prone to digital gangrene and a high serum CRP level predicted poor outcomes. The CRP level should be efficiently controlled to ensure a good prognosis.
Collapse
Affiliation(s)
- Lin Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,The Department of Rheumatology, 2nd Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaodan Kong
- The Department of Rheumatology, 2nd Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China
| | - Jiaxin Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China
| | - Dong Xu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China
| |
Collapse
|
20
|
Muacevic A, Adler JR. Polyarteritis Nodosa Following mRNA-1273 COVID-19 Vaccination: Case Study and Review of Immunological Mechanisms. Cureus 2023; 15:e33620. [PMID: 36788908 PMCID: PMC9911313 DOI: 10.7759/cureus.33620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 01/12/2023] Open
Abstract
Numerous post-vaccine complications have been reported secondary to the COVID-19 vaccine. Many of these complications are believed to be due to a hyperactive immune system. A 59-year-old woman developed diffuse abdominal pain two days after receiving the mRNA-1273 COVID-19 vaccine (Moderna). A computerized tomography (CT) angiogram of the abdomen and pelvis revealed the presence of numerous vascular irregularities in the celiac axis, bilateral renal arteries, and inferior mesenteric artery consistent with polyarteritis nodosa (PAN), a medium-vessel vasculitis. The patient was managed with intravenous methylprednisolone 500 mg daily for three days and was then placed on oral methotrexate (MTX) 12.5 mg daily for immunosuppressive maintenance treatment. Until now, a limited number of cases of polyarteritis nodosa secondary to the COVID-19 vaccine have been reported. Major mechanisms of post-vaccine autoimmunity are molecular mimicry and autoantibody production. Although rare adverse events from COVID-19 vaccination are possible, there remains an immense benefit to vaccination in preventing COVID-19-related morbidity and mortality.
Collapse
|
21
|
Esin RG, Fatykhova AF, Esin OR. [Vasculitis as a cause of stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:5-11. [PMID: 38148691 DOI: 10.17116/jnevro20231231225] [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: 12/28/2023]
Abstract
The review considers the clinical picture, key aspects of the diagnosis and treatment of vasculitis that are the causes of strokes (giant cell arteritis, polyarteritis nodosa, varicella zoster virus vasculopathy, cerebrovascular pathology caused by herpes simplex virus types 1 and 2, primary CNS angiitis, adenosine deaminase-2 deficiency).
Collapse
Affiliation(s)
- R G Esin
- Kazan (Volga region) Federal University, Kazan, Russia
- Kazan State Medical Academy, Kazan, Russia
| | - A F Fatykhova
- Kazan (Volga region) Federal University, Kazan, Russia
| | - O R Esin
- Kazan (Volga region) Federal University, Kazan, Russia
- Clinic of Otorhinolaryngology, Kazan, Russia
| |
Collapse
|
22
|
Bromfield B, Tellez R, Novelli P, Duarte-Rojo A. Hepatic artery pseudoaneurysms and hepatic ischaemic injury: a rare complication of polyarteritis nodosa. BMJ Case Rep 2022; 15:e251432. [PMID: 36450409 PMCID: PMC9716803 DOI: 10.1136/bcr-2022-251432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
A woman in her 70s presented with months of intermittent fevers, severe fatigue, headaches, abdominal pain and haematuria. She developed acute onset left-sided weakness and was found to have radiographic evidence of right frontal and left parietal intraparenchymal haemorrhages with subarachnoid haemorrhage. She also had markedly elevated liver transaminases with subsequent abdominal MRI that revealed hepatic artery pseudoaneurysms (HAP) requiring embolisation. The case required a multidisciplinary approach consisting of hepatology, interventional radiology and rheumatology. Ultimately, the aetiology was attributed to polyarteritis nodosa (PAN). Through this case report, we highlight HAP as an extremely rare complication of PAN. Although it is a challenging diagnosis to make, it has a favourable response to immunosuppression with high-dose corticosteroids.
Collapse
Affiliation(s)
| | | | - Paula Novelli
- Radiology and Interventional Radiology, UPMC, Pittsburgh, Pennsylvania, USA
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Northwestern, Chicago, Illinois, USA
| |
Collapse
|
23
|
Aymonnier K, Amsler J, Lamprecht P, Salama A, Witko‐Sarsat V. The neutrophil: A key resourceful agent in immune‐mediated vasculitis. Immunol Rev 2022; 314:326-356. [PMID: 36408947 DOI: 10.1111/imr.13170] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The term "vasculitis" refers to a group of rare immune-mediated diseases characterized by the dysregulated immune system attacking blood vessels located in any organ of the body, including the skin, lungs, and kidneys. Vasculitides are classified according to the size of the vessel that is affected. Although this observation is not specific to small-, medium-, or large-vessel vasculitides, patients show a high circulating neutrophil-to-lymphocyte ratio, suggesting the direct or indirect involvement of neutrophils in these diseases. As first responders to infection or inflammation, neutrophils release cytotoxic mediators, including reactive oxygen species, proteases, and neutrophil extracellular traps. If not controlled, this dangerous arsenal can injure the vascular system, which acts as the main transport route for neutrophils, thereby amplifying the initial inflammatory stimulus and the recruitment of immune cells. This review highlights the ability of neutrophils to "set the tone" for immune cells and other cells in the vessel wall. Considering both their long-established and newly described roles, we extend their functions far beyond their direct host-damaging potential. We also review the roles of neutrophils in various types of primary vasculitis, including immune complex vasculitis, anti-neutrophil cytoplasmic antibody-associated vasculitis, polyarteritis nodosa, Kawasaki disease, giant cell arteritis, Takayasu arteritis, and Behçet's disease.
Collapse
Affiliation(s)
- Karen Aymonnier
- INSERM U1016, Institut Cochin, Université Paris Cité, CNRS 8104 Paris France
| | - Jennifer Amsler
- INSERM U1016, Institut Cochin, Université Paris Cité, CNRS 8104 Paris France
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology University of Lübeck Lübeck Germany
| | - Alan Salama
- Department of Renal Medicine, Royal Free Hospital University College London London UK
| | | |
Collapse
|
24
|
Ohmura SI, Ohkubo Y, Ishihara R, Otsuki Y, Miyamoto T. Medium-vessel Vasculitis Presenting with Myalgia Following COVID-19 Moderna Vaccination. Intern Med 2022; 61:3453-3457. [PMID: 36070946 PMCID: PMC9751726 DOI: 10.2169/internalmedicine.0293-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) vaccines have been delivered worldwide to prevent the spread of the disease, and almost all Japanese have received the mRNA vaccines "BNT162b2" (Pfizer-BioNTech) or "mRNA-1273" (Moderna). These vaccines have shown efficacy and safety with only minor adverse drug reactions. However, some patients develop severe adverse drug reactions, including autoimmune reactions. In addition, systemic vasculitis, mainly small-vessel vasculitis, following COVID-19 vaccination, has been reported. However, only a few investigators have reported medium-vessel vasculitis following vaccination. We herein report a case of medium-vessel vasculitis presenting with myalgia as the initial clinical manifestation following COVID-19 Moderna vaccination.
Collapse
Affiliation(s)
- Shin-Ichiro Ohmura
- Department of Rheumatology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Yusuke Ohkubo
- Department of Rheumatology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Ryuhei Ishihara
- Department of Rheumatology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Yoshiro Otsuki
- Department of Pathology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Toshiaki Miyamoto
- Department of Rheumatology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| |
Collapse
|
25
|
Katz G, Wallace ZS. Environmental Triggers for Vasculitis. Rheum Dis Clin North Am 2022; 48:875-890. [PMID: 36333001 DOI: 10.1016/j.rdc.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systemic vasculitides are autoimmune diseases characterized by vascular inflammation. Most types of vasculitis are thought to result from antigen exposure in genetically susceptible individuals, suggesting a likely role for environmental triggers in these conditions. Seasonal and geographic variations in incidence provide insight into the potential role of environmental exposures in these diseases. Many data support infectious triggers in some vasculitides, whereas other studies have identified noninfectious triggers, such as airborne pollutants, silica, smoking, and heavy metals. We review the known and suspected environmental triggers in giant cell arteritis, Takayasu arteritis, polyarteritis nodosa, Kawasaki disease, and antineutrophil cytoplasmic antibody-associated vasculitis.
Collapse
Affiliation(s)
- Guy Katz
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Bulfinch 165, 55 Fruit Street, Boston, MA 02114, USA
| | - Zachary S Wallace
- Clinical Epidemiology Program, Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Mongan Institute, Massachusetts General Hospital, Harvard Medical School, 100 Cambridge Street, Boston, MA 02114, USA.
| |
Collapse
|
26
|
A comprehensive guide for managing the reproductive health of patients with vasculitis. Nat Rev Rheumatol 2022; 18:711-723. [PMID: 36192559 PMCID: PMC9529165 DOI: 10.1038/s41584-022-00842-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 11/08/2022]
Abstract
Vasculitides and their therapies affect all areas of the reproductive life cycle. The ACR, EULAR and the Drugs and Lactation database offer guidance on the management of the reproductive health of patients with rheumatic diseases; however, these guidelines do not address patients with vasculitis specifically. This Review discusses the guidance from multiple expert panels and how these recommendations might apply to men and women with vasculitis, including the safety of contraception, use of assisted reproductive technology, preservation of fertility during cyclophosphamide therapy, disease management in pregnancy and the use of medications compatible with pregnancy and lactation. These discussions are augmented by the existing literature on vasculitis in pregnancy to enable physicians to provide comprehensive, precise and high quality care to patients with vasculitis. The contents of this Review, in conjunction with educational tools, serve to empower patients and physicians to participate in shared decision-making regarding pregnancy prevention, planning and management. This Review discusses how best to manage the reproductive health of patients with vasculitis, including the safety of contraception, the use of assisted reproductive technology, preservation of fertility during therapy, disease management in pregnancy and the use of medications compatible with pregnancy and lactation. Rheumatologists have the opportunity to initiate discussions with patients with vasculitis regarding family planning to make proactive decisions leading to improved pregnancy planning, management and outcomes. Birth control options and infertility interventions for women with vasculitis depend on their risk of thrombosis, serological profile and comorbid conditions. The majority of pregnancies in patients with vasculitis can be successful with the use of advanced family planning, medications compatible with pregnancy and lactation, and multidisciplinary collaboration among specialists. Vasculitis exacerbations and pregnancy complications can present with similar and overlapping clinical manifestations. Multiple expert panels provide guidelines and risk stratification regarding medication use in pregnancy and breastfeeding that can be applied to patients with vasculitis.
Collapse
|
27
|
Muacevic A, Adler JR. Differential Diagnosis of Multiple Systemic Aneurysms. Cureus 2022; 14:e30043. [PMID: 36381690 PMCID: PMC9637480 DOI: 10.7759/cureus.30043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2022] [Indexed: 01/24/2023] Open
Abstract
Atherosclerosis and systemic hypertension are the most common pathogeneses of solitary acquired arterial aneurysms. The rare occurrence of multiple synchronous or metachronous arterial aneurysms requires considering alternative underlying causes. We present the unusual case of a male patient who sequentially developed multiple co-existing arterial aneurysms between the ages of 51 and 59. The sites of involvement included high-pressure systemic arteries and low-pressure pulmonary arteries. We discuss the broad differential diagnosis that includes heritable and non-inheritable etiologies. A keen clinical awareness of this broader array of arterial aneurysms is essential for accurate early diagnosis and proper management.
Collapse
|
28
|
Amouei M, Momtazmanesh S, Kavosi H, Davarpanah AH, Shirkhoda A, Radmard AR. Imaging of intestinal vasculitis focusing on MR and CT enterography: a two-way street between radiologic findings and clinical data. Insights Imaging 2022; 13:143. [PMID: 36057741 PMCID: PMC9440973 DOI: 10.1186/s13244-022-01284-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/04/2022] [Indexed: 11/21/2022] Open
Abstract
Diagnosis of intestinal vasculitis is often challenging due to the non-specific clinical and imaging findings. Vasculitides with gastrointestinal (GI) manifestations are rare, but their diagnosis holds immense significance as late or missed recognition can result in high mortality rates. Given the resemblance of radiologic findings with some other entities, GI vasculitis is often overlooked on small bowel studies done using computed tomography/magnetic resonance enterography (CTE/MRE). Hereon, we reviewed radiologic findings of vasculitis with gastrointestinal involvement on CTE and MRE. The variety of findings on MRE/CTE depend upon the size of the involved vessels. Signs of intestinal ischemia, e.g., mural thickening, submucosal edema, mural hyperenhancement, and restricted diffusion on diffusion-weighted imaging, are common in intestinal vasculitis. Involvement of the abdominal aorta and the major visceral arteries is presented as concentric mural thickening, transmural calcification, luminal stenosis, occlusion, aneurysmal changes, and collateral vessels. Such findings can be observed particularly in large- and medium-vessel vasculitis. The presence of extra-intestinal findings, including within the liver, kidneys, or spleen in the form of focal areas of infarction or heterogeneous enhancement due to microvascular involvement, can be another radiologic clue in diagnosis of vasculitis. The link between the clinical/laboratory findings and MRE/CTE abnormalities needs to be corresponded when it comes to the diagnosis of intestinal vasculitis.
Collapse
Affiliation(s)
- Mehrnam Amouei
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, North Kargar St., Tehran, 14117, Iran
| | - Sara Momtazmanesh
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, North Kargar St., Tehran, 14117, Iran
| | - Hoda Kavosi
- Department of Rheumatology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir H Davarpanah
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, USA
| | - Ali Shirkhoda
- Department of Radiological Science, University of California at Irvine, Irvine, USA
| | - Amir Reza Radmard
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, North Kargar St., Tehran, 14117, Iran.
| |
Collapse
|
29
|
Heartshorne R, Nwe M, Barakat A, Alusi S. Polyarteritis nodosa presenting with posterior reversible leukoencephalopathy syndrome. BMJ Case Rep 2022; 15:e250867. [PMID: 36129358 PMCID: PMC9438085 DOI: 10.1136/bcr-2022-250867] [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] [Accepted: 07/23/2022] [Indexed: 11/03/2022] Open
Abstract
A man in his 20s presented following a generalised tonic-clonic seizure on a background of a recent diagnosis of hepatitis B (HBV). During admission, he was severely hypertensive and imaging findings confirmed a diagnosis of posterior reversible leukoencephalopathy syndrome (PRES). The patient subsequently developed multiorgan involvement with an axonal sensorimotor neuropathy, vascular cutaneous lesions and multiple bilateral renal and splenic infarcts. Based on the 2012 Revised International Chapel Hill Consensus Criteria, a diagnosis of polyarteritis nodosa (PAN) with secondary PRES was made. The patient was given intravenous methylprednisolone, followed by a prolonged course of oral prednisolone, and tenofovir antiviral therapy to target HBV seroconversion. He made a good neurological recovery with resolution of imaging changes. This case highlights the importance of a low threshold for systemic screening for young patients presenting with PRES secondary to uncontrolled hypertension and the importance of viral screening, particularly for HBV.
Collapse
Affiliation(s)
| | - May Nwe
- Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Athar Barakat
- Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Sundus Alusi
- Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| |
Collapse
|
30
|
Skeik N, Smith J, Olson SL, Lohese OL, Mirza A, Manunga J. Mesenteric Artery Dissection and Wall-Thickening, Case Study and General Review. Angiology 2022:33197221100601. [PMID: 35921630 DOI: 10.1177/00033197221100601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mesenteric artery dissection (D) and wall-thickening (WT) are rare vasculopathies that can lead to serious complications. This is a single center analysis of all patients evaluated for mesenteric arterial (celiac, superior (SMA) and/or inferior mesenteric (IMA)) D and/or WT from January 1, 2000, to January 31, 2020 at our hospital. Among the 101 included patients, the average age was 55.6 ± 13.6 years, mostly affecting men (62%). There were 20 celiac artery D, 8 WT, 15 D with WT, 15 SMA D, 7 WT, 8 D with WT, one IMA D, two WT, and 25 with multiple arterial involvement. Primary etiologies included segmental arterial mediolysis (SAM) (n = 17), isolated D (n = 17), localized vasculitis of the gastrointestinal tract (LVGT) (n = 16), fibromuscular dysplasia (FMD) (n = 13), extension of thoracoabdominal aortic D (n = 12), and trauma (n = 12). Most (71%) patients presented with abdominal pain. Hypertension (55%), hyperlipidemia (33%) and tobacco use (31%) were prevalent. Management included conservative (22%), medical (47%), endovascular (19%), and/or open repair (12%) with high in-hospital survival (98%) and symptom relief (73%). Our paper complements the scarce literature addressing the diagnosis and management of rare mesenteric vasculopathies. Most patients improved with conservative management, reserving endovascular or surgical interventions for symptomatic patients with more complicated presentations.
Collapse
Affiliation(s)
- Nedaa Skeik
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA.,51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Jenna Smith
- 51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Sydney L Olson
- 12244Northwestern University Feiberg School of Medicine, Chicago, IL, USA
| | - Opema L Lohese
- 51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Aleem Mirza
- Department of Cardiovascular and Vascular Surgery, 12340University of Texas Health Science, Houston, TX, USA
| | - Jesse Manunga
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA.,51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| |
Collapse
|
31
|
Özdemir Atikel Y, Derinkuyu BE, Bakkaloğlu SA. Unusual presentation of familial Mediterranean fever with co-existing polyarteritis nodosa and acute post-streptococcal glomerulonephritis. Clin Case Rep 2022; 10:e6022. [PMID: 35898740 PMCID: PMC9307881 DOI: 10.1002/ccr3.6022] [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: 11/11/2021] [Revised: 03/05/2022] [Accepted: 05/22/2022] [Indexed: 11/16/2022] Open
Abstract
Acute post-streptococcal glomerulonephritis (APSGN) and polyarteritis nodosa (PAN) may occur simultaneously after streptococcal infection in a child who is previously healthy but carries a Mediterranean fever (MEFV) mutation. The homozygous M694V mutation in the MEFV gene may cause an augmented response to the streptococcal infection that plays a role in the development of both clinical manifestations.
Collapse
Affiliation(s)
- Yeşim Özdemir Atikel
- Department of Pediatric NephrologyGazi University Faculty of MedicineAnkaraTurkey
| | | | - Sevcan A. Bakkaloğlu
- Department of Pediatric NephrologyGazi University Faculty of MedicineAnkaraTurkey
- Department of Pediatric RheumatologyGazi University Faculty of MedicineAnkaraTurkey
| |
Collapse
|
32
|
Waisayarat J, Niyasom C, Vilaiyuk S, Molagool S. Polyarteritis Nodosa with Cytomegalovirus Enteritis and Jejunoileal Perforation: Report of a Case with a Literature Review. Vasc Health Risk Manag 2022; 18:595-601. [PMID: 35924006 PMCID: PMC9342704 DOI: 10.2147/vhrm.s354548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 07/19/2022] [Indexed: 12/29/2022] Open
Abstract
Polyarteritis nodosa (PAN) is a rare systemic necrotizing vasculitis affecting small- to medium-sized arteries. The most common gastrointestinal manifestation of PAN is postprandial abdominal pain from mesenteric arteritis causing bowel ischemia. When transmural ischemia develops, there may be ischemic necrosis and perforation of the bowel wall, which are life-threatening. Severe, life-threatening gastrointestinal involvement is relatively rare in pediatric PAN and may require different management in adult patients. We report a pediatric PAN case in a patient who presented with acute abdominal pain and superimposed cytomegalovirus enteritis with jejunoileal perforation. The patient improved with emergency small intestinal resection followed by conventional immunosuppressive drugs of a corticosteroid and cyclophosphamide, and anti-viral drugs. Before increasing the immunosuppressive drug dosage, initial screening of infectious cytomegalovirus and comprehensive evaluation for surgical conditions are essential in pediatric PAN with severe gastrointestinal involvement. Early aggressive treatment for acute abdomen is useful in reducing morbidity and mortality in pediatric PAN.
Collapse
Affiliation(s)
- Jariya Waisayarat
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Correspondence: Jariya Waisayarat, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Rajathevee, Bangkok, 10400, Thailand, Tel +66 2 201 1432, Fax +66 2 354 7266, Email
| | - Chayakamon Niyasom
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Soamarat Vilaiyuk
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sani Molagool
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
33
|
Angiographic characteristics of vasculopathy in patients with idiopathic inflammatory myopathies and systemic sclerosis. Sci Rep 2022; 12:9051. [PMID: 35641535 PMCID: PMC9156678 DOI: 10.1038/s41598-022-12991-y] [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: 08/20/2021] [Accepted: 05/11/2022] [Indexed: 11/28/2022] Open
Abstract
To describe the peripheral angiographic features of vasculopathy in idiopathic inflammatory myopathies (IIM) and systemic sclerosis (SSc) in comparison to polyarteritis nodosa (PAN). Angiograms of 47 extremities (24 upper and 23 lower) of 11 patients with IIM (n = 5) and SSc (n = 6), and 12 patients with PAN who presented with critical limb ischemia were retrospectively analyzed with regards to the presence of stenosis, occlusion, aneurysms and delayed distal flow, and degree of neovascularization. Diffuse narrowing was more frequent (66.1 vs. 38.0%, p = 0.001), whereas multifocal stenosis (6.5% vs. 26.8%, p = 0.002), abrupt occlusion (11.3% vs. 29.6%, p = 0.010) and aneurysm formation (1.6% vs. 11.3%, p = 0.037) were less frequent in IIM/SSc than PAN. In distal arteries, tapered occlusion (95.5% vs. 76.0%, p = ns) and delayed flow (77.3% vs. 48.0%, p = 0.039) were more common in IIM/SSc than PAN. After 1 year, auto- or surgical amputation tended to be more frequent in IIM/SSc than PAN (36.4% vs. 16.7%, p = ns). In conclusion, diffuse narrowing, tapered occlusion and delayed distal flow on conventional angiograms tend to be more frequent in IIM/SSc than PAN. Further studies are needed to verify these findings in a larger prospective cohort.
Collapse
|
34
|
Myocardial Infarction in a 7-Year-Old Girl with Polyarteritis Nodosa. Case Rep Rheumatol 2022; 2022:2175676. [PMID: 35516168 PMCID: PMC9064490 DOI: 10.1155/2022/2175676] [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: 11/05/2021] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 11/29/2022] Open
Abstract
Polyarteritis nodosa (PAN) is a rare systemic vasculitis that affects small to medium-sized arteries. It could affect any organ including the heart. However coronary artery involvements are very rare. We describe a young girl who presented following a histopathological diagnosis of PAN with acute chest pain, high serum troponin, and progressive ischemic changes in the electrocardiogram (ECG). Induction of remission of her disease was done with six-moths Cyclophosphamide infusions and pulse corticosteroids. In addition to anticoagulation and dual antithrombotic therapy, the disease remission was maintained with mycophenolate mofetil which helps in the recovery of coronary disease. Our case illustrates the serious cardiac involvement of PAN in a child that responded to intensive management.
Collapse
|
35
|
Jin K, Parreau S, Warrington KJ, Koster MJ, Berry GJ, Goronzy JJ, Weyand CM. Regulatory T Cells in Autoimmune Vasculitis. Front Immunol 2022; 13:844300. [PMID: 35296082 PMCID: PMC8918523 DOI: 10.3389/fimmu.2022.844300] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/28/2022] [Indexed: 12/14/2022] Open
Abstract
Blood vessels are indispensable for host survival and are protected from inappropriate inflammation by immune privilege. This protection is lost in patients with autoimmune vasculitides, a heterogeneous group of diseases causing damage to arteries, arterioles, and capillaries. Vasculitis leads to vascular wall destruction and/or luminal occlusion, resulting in hemorrhage and tissue ischemia. Failure in the quantity and quality of immunosuppressive regulatory T cells (Treg) has been implicated in the breakdown of the vascular immune privilege. Emerging data suggest that Treg deficiencies are disease-specific, affecting distinct pathways in distinct vasculitides. Mechanistic studies have identified faulty CD8+ Tregs in Giant Cell Arteritis (GCA), a vasculitis of the aorta and the large aortic branch vessels. Specifically, aberrant signaling through the NOTCH4 receptor expressed on CD8+ Treg cells leads to rerouting of intracellular vesicle trafficking and failure in the release of immunosuppressive exosomes, ultimately boosting inflammatory attack to medium and large arteries. In Kawasaki’s disease, a medium vessel vasculitis targeting the coronary arteries, aberrant expression of miR-155 and dysregulated STAT5 signaling have been implicated in undermining CD4+ Treg function. Explorations of mechanisms leading to insufficient immunosuppression and uncontrolled vascular inflammation hold the promise to discover novel therapeutic interventions that could potentially restore the immune privilege of blood vessels and pave the way for urgently needed innovations in vasculitis management.
Collapse
Affiliation(s)
- Ke Jin
- Department of Medicine, Mayo College of Medicine and Science, Rochester, MN, United States
| | - Simon Parreau
- Department of Medicine, Mayo College of Medicine and Science, Rochester, MN, United States
| | - Kenneth J. Warrington
- Department of Medicine, Mayo College of Medicine and Science, Rochester, MN, United States
| | - Matthew J. Koster
- Department of Medicine, Mayo College of Medicine and Science, Rochester, MN, United States
| | - Gerald J. Berry
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Jörg J. Goronzy
- Department of Medicine, Mayo College of Medicine and Science, Rochester, MN, United States
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Cornelia M. Weyand
- Department of Medicine, Mayo College of Medicine and Science, Rochester, MN, United States
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
- *Correspondence: Cornelia M. Weyand,
| |
Collapse
|
36
|
Robinson C, Yasin Z, Patel P, Zebda H. A Rare Presentation of Polyarteritis Nodosa. Cureus 2022; 14:e21925. [PMID: 35273868 PMCID: PMC8901107 DOI: 10.7759/cureus.21925] [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] [Accepted: 02/04/2022] [Indexed: 11/17/2022] Open
Abstract
Polyarteritis nodosa (PAN) is a rare form of necrotizing medium-vessel vasculitis. PAN has the potential for widespread organ involvement, but the skin, renal, neurologic, and musculoskeletal systems are most commonly involved. A definitive diagnosis can be made with a biopsy of an easily accessible organ such as the skin or an involved nerve or muscle. We present a case of a 66-year-old female with no significant past medical history who presented with chest and epigastric pain. She was subsequently found to have computed tomography angiography (CTA) findings consistent with PAN, including areas of arterial narrowing alternating with areas of aneurysmal dilation confined to the mesenteric arteries. A biopsy of the involved arteries was deemed unsafe and ultimately not performed. Her lab findings were remarkable for elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) and unremarkable for a broad infectious disease workup. Suspicion of PAN was further strengthened by a positive response to, and eventual full recovery on, high-dose steroids alone.
Collapse
|
37
|
Diagnostic and Therapeutic Challenges of Vasculitis. Can J Cardiol 2022; 38:623-633. [DOI: 10.1016/j.cjca.2022.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 12/17/2022] Open
|
38
|
Wada T, Kondo E, Shibata E, Sakuragi T, Iio K, Uchimura T, Kinjo Y, Murakami M, Yoshino K. Difficulties in Differentiating Hypertensive Disorders of Pregnancy With Polyarteritis Nodosa. J Med Cases 2022; 13:5-10. [PMID: 35211228 PMCID: PMC8827254 DOI: 10.14740/jmc3813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/27/2021] [Indexed: 11/20/2022] Open
Abstract
Polyarteritis nodosa (PAN) is characterized by medium- or small-sized artery vasculitis with vessel wall inflammation and necrosis of muscular arteries, commonly presenting with fatigue, fever, weight loss, and joint pain. PAN in pregnancy is rare and is associated with worsening of vasculitis after delivery, resulting in myocardial infarction and heart failure which frequently lead to maternal death. We report a case of hypertensive disorders of pregnancy (HDP), which is difficult to differentiate from PAN. A 27-year-old multigravida was diagnosed with PAN 4 years prior after experiencing fever and lower extremity skin rash. During her PAN remission, she conceived her second pregnancy and opted to discontinue PAN medication and declined antihypertensive medications. At 22 weeks of gestation, her blood pressure was elevated to 200/100 mm Hg without proteinuria, for which she was admitted to our hospital. She was diagnosed with HDP-chronic hypertension without PAN recurrence due to the absence of PAN-specific skin or joint symptoms according to the PAN diagnostic criteria. Antihypertensive medication was administered. At 30 weeks of gestation, her blood pressure was poorly controlled and she developed proteinuria, which led to a diagnosis of superimposed preeclampsia that necessitated emergency cesarean section delivery. After delivery, her blood pressure was immediately controlled using antihypertensive medication. Our case report highlights the importance of carefully managing HPD as a serious complication of PAN.
Collapse
Affiliation(s)
- Tamaki Wada
- Department of Obstetrics and Gynecology, Institution of University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Emi Kondo
- Department of Obstetrics and Gynecology, Institution of University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan,Corresponding Author: Emi Kondo, Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka 857-8556, Japan.
| | - Eiji Shibata
- Department of Obstetrics and Gynecology, Institution of University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Toshihide Sakuragi
- Department of Obstetrics and Gynecology, Institution of University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Kazuaki Iio
- Department of Obstetrics and Gynecology, Institution of University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Takayuki Uchimura
- Department of Obstetrics and Gynecology, Institution of University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Yasuyuki Kinjo
- Department of Obstetrics and Gynecology, Institution of University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Midori Murakami
- Department of Obstetrics and Gynecology, Institution of University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Kiyoshi Yoshino
- Department of Obstetrics and Gynecology, Institution of University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| |
Collapse
|
39
|
Yokota K, Kurihara I, Nakamura T, Nakatsuka S, Miyashita K, Kobayashi S, Murai-Takeda A, Sone M, Itoh H. Remission of Angiographically Confirmed Minocycline-induced Renal Polyarteritis Nodosa: A Case Report and Literature Review. Intern Med 2022; 61:103-110. [PMID: 34176836 PMCID: PMC8810245 DOI: 10.2169/internalmedicine.7340-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 23-year-old man presented with severe hypertension. Based on his history of minocycline treatment for over three years and clinical symptoms, such as myalgias and renovascular hypertension with multiple intrarenal aneurysms, he was diagnosed with minocycline-induced renal polyarteritis nodosa (PAN). After minocycline treatment cessation and management of the hypertension, his blood pressure, renin-aldosterone levels, and urinary protein levels gradually improved. Seven and a half years later, repeated angiography found that the aneurysms had resolved. This is the first report in English describing a case of minocycline-induced renal PAN that was reversed functionally and morphologically without steroids or immunosuppressive drugs.
Collapse
Affiliation(s)
- Kenichi Yokota
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Isao Kurihara
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Toshifumi Nakamura
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Seishi Nakatsuka
- Department of Radiology, Keio University School of Medicine, Japan
| | | | - Sakiko Kobayashi
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Ayano Murai-Takeda
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Masakatsu Sone
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Hiroshi Itoh
- Department of Internal Medicine, Keio University School of Medicine, Japan
| |
Collapse
|
40
|
Schiffmann ML, Dissemond J, Erfurt-Berge C, Hafner J, Itzlinger-Monshi BA, Jungkunz HW, Kahle B, Kreuter A, Scharffetter-Kochanek K, Lutze S, Rappersberger K, Schneider SW, Strölin A, Sunderkötter C, Goerge T. S1-Leitlinie Diagnostik und Therapie der Livedovaskulopathie. J Dtsch Dermatol Ges 2021; 19:1667-1678. [PMID: 34811901 DOI: 10.1111/ddg.14520_g] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/18/2021] [Indexed: 11/26/2022]
Affiliation(s)
| | | | | | | | | | | | - Birgit Kahle
- Universitätsklinikum Schleswig-Holstein, Campus Lübeck
| | | | | | | | | | | | | | | | - Tobias Goerge
- Klinik für Hautkrankheiten, Universitätsklinik Münster
| |
Collapse
|
41
|
Abon JCR, Lopez MPJ, Berberabe A, Cinco KJ. Pancreaticoduodenal artery aneurysm associated with polyarteritis nodosa presenting as massive upper gastrointestinal bleeding. BMJ Case Rep 2021; 14:e247359. [PMID: 34799396 PMCID: PMC8606768 DOI: 10.1136/bcr-2021-247359] [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] [Accepted: 10/23/2021] [Indexed: 11/04/2022] Open
Abstract
The pancreaticoduodenal arteries are rare sites for true aneurysm formation, but these may develop in association with occlusion of the coeliac circulation, degenerative conditions or inflammatory vascular disorders. These have a high risk of rupture regardless of size or other factors. One identified cause is polyarteritis nodosa (PAN), which is an autoimmune necrotising vascular condition that affects small-sized and medium-sized arteries. We report a case of a 40-year-old man with massive gastrointestinal tract bleeding from a ruptured pancreaticoduodenal artery aneurysm secondary to PAN. This was managed with emergent open aneurysm ligation followed by high-dose corticosteroids and cyclophosphamide pulse therapy. Only three other cases of PAN-associated pancreaticoduodenal artery aneurysms have been reported in the literature.
Collapse
Affiliation(s)
| | - Marc Paul Jose Lopez
- Department of Surgery, University of the Philippines Manila, Manila, Philippines
| | - A'Ericson Berberabe
- Department of Surgery, University of the Philippines Manila, Manila, Philippines
| | - Kenan Jared Cinco
- Department of Surgery, University of the Philippines Manila, Manila, Philippines
| |
Collapse
|
42
|
Schiffmann ML, Dissemond J, Erfurt-Berge C, Hafner J, Itzlinger-Monshi BA, Jungkunz HW, Kahle B, Kreuter A, Scharffetter-Kochanek K, Lutze S, Rappersberger K, Schneider SW, Strölin A, Sunderkötter C, Goerge T. German S1 guideline: diagnosis and treatment of livedovasculopathy. J Dtsch Dermatol Ges 2021; 19:1668-1678. [PMID: 34739187 DOI: 10.1111/ddg.14520] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/18/2021] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | | | | | | | - Birgit Kahle
- University Hospital Schleswig-Holstein, Campus Lübeck
| | | | | | | | | | | | | | | | - Tobias Goerge
- Department of Skin Diseases, University Hospital Münster
| |
Collapse
|
43
|
Nomura S, Shimojima Y, Kondo Y, Kishida D, Sekijima Y. Hypertrophic pachymeningitis in polyarteritis nodosa: a case-based review. Clin Rheumatol 2021; 41:567-572. [PMID: 34725743 DOI: 10.1007/s10067-021-05971-6] [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: 09/24/2021] [Revised: 10/13/2021] [Accepted: 10/16/2021] [Indexed: 11/29/2022]
Abstract
Hypertrophic pachymeningitis (HP) is a rare neurological disorder with focal or diffuse thickening of the dura mater, which usually causes headache, cranial neuropathies, seizures, and motor or sensory impairments. The development of HP is attributed to an immune-mediated mechanism, and some autoimmune diseases have been implicated in the development of HP. Herein, we describe the case of a 73-year-old woman with persistent headache ascribable to HP, which developed approximately 3 years after a diagnosis of polyarteritis nodosa (PAN). She was treated with high-dose corticosteroid and cyclophosphamide that resulted in immediate disappearance of headache and improved radiological findings of thickened dura mater. In addition, she was subsequently administered methotrexate, ultimately resulting in maintenance of remission and regular reduction of prednisolone. In our review of published English articles, only two cases of HP in patients with PAN have been reported to date, suggesting that HP is a rare complication in PAN. However, it should be recognized that HP may develop as a neurological involvement related to PAN.
Collapse
Affiliation(s)
- Shun Nomura
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
| | - Yasufumi Kondo
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Dai Kishida
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| |
Collapse
|
44
|
de Boysson H, Pagnoux C. Vasculiti del sistema nervoso centrale. Neurologia 2021. [DOI: 10.1016/s1634-7072(21)45782-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
45
|
Galetta K, Bhattacharyya S. Acute Neurologic Manifestations of Systemic Immune-Mediated Diseases. Semin Neurol 2021; 41:541-553. [PMID: 34619780 DOI: 10.1055/s-0041-1733790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Systemic autoimmune diseases can affect the peripheral and central nervous system. In this review, we outline the common inpatient consultations for patients with neurological symptoms from rheumatoid arthritis, Sjogren's syndrome, systemic lupus erythematosus, sarcoidosis, immunoglobulin G4-related disease, Behçet's disease, giant cell arteritis, granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis, polyarteritis nodosa, and ankylosing spondylitis. We discuss the symptoms, diagnostic strategies, and treatment options.
Collapse
Affiliation(s)
- Kristin Galetta
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shamik Bhattacharyya
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
46
|
Papachristodoulou E, Kakoullis L, Tiniakou E, Parperis K. Therapeutic options for cutaneous polyarteritis nodosa: a systematic review. Rheumatology (Oxford) 2021; 60:4039-4047. [PMID: 33944902 DOI: 10.1093/rheumatology/keab402] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/23/2021] [Accepted: 04/28/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Cutaneous polyarteritis nodosa (CPAN) is a necrotizing vasculitis of the middle-size vessels, confined to the skin. We conducted a systematic review in order to identify studies evaluating the different treatment modalities used in CPAN. METHODS This systematic review was conducted according to PRISMA guidelines, registered in PROSPERO: CRD42020222195. PubMed/Medline databases were searched from inception to December of 2020 using the terms: (Polyarteritis nodosa[Title/Abstract]) AND ((therapy[Title/Abstract]) OR (management[Title/Abstract]) OR (treatment[Title/Abstract]))' and 'Cutaneous arteritis [Title/Abstract]'. Articles evaluating pertaining to the management of CPAN in adults were eligible for inclusion. RESULTS A total of seven eligible case series with 325 unique patients were included. No study included a control population. In general, systemic corticosteroids were widely used as induction treatment. Immunosuppressive agents combined with corticosteroids were AZA, hydroxychloroquine, sulfasalazine, sulphapyridine, CYC, MTX, mycophenolate, tacrolimus, rituxima and thalidomide. Other agents utilized in the studies were dapsone, colchicine, non-steroid anti-inflammatory drugs, salicylates, warfarin and clopidogrel. In some studies, the presence of ulcerations was associated with an increased risk of relapse. CONCLUSION The evidence available regarding the management of patients with CPAN is limited at best. Further studies are needed in order to evaluate the effect of treatment on disease remission, relapses and mortality.
Collapse
Affiliation(s)
| | - Loukas Kakoullis
- Department of Medicine, University of Cyprus Medical School, Nicosia, Cyprus
| | - Eleni Tiniakou
- Department of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Konstantinos Parperis
- Department of Internal Medicine, Division of Rheumatology, University of Cyprus Medical School, Nicosia, Cyprus.,Department of Medicine, Division of Rheumatology, University of Arizona College of Medicine, Phoenix, AZ, USA
| |
Collapse
|
47
|
Chung SA, Gorelik M, Langford CA, Maz M, Abril A, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot M, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Polyarteritis Nodosa. Arthritis Rheumatol 2021; 73:1384-1393. [PMID: 34235883 DOI: 10.1002/art.41776] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/13/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of systemic polyarteritis nodosa (PAN). METHODS Twenty-one clinical questions regarding diagnostic testing, treatment, and management were developed in the population, intervention, comparator, and outcome (PICO) format for systemic, non-hepatitis B-related PAN. Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence and formulate recommendations. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 16 recommendations and 1 ungraded position statement for PAN. Most recommendations were graded as conditional due to the paucity of evidence. These recommendations support early treatment of severe PAN with cyclophosphamide and glucocorticoids, limiting toxicity through minimizing long-term exposure to both treatments, and the use of imaging and tissue biopsy for disease diagnosis. These recommendations endorse minimizing risk to the patient by using established therapy at disease onset and identify new areas where adjunctive therapy may be warranted. CONCLUSION These recommendations provide guidance regarding diagnostic strategies, use of pharmacologic agents, and imaging for patients with PAN.
Collapse
Affiliation(s)
| | | | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
48
|
Chung SA, Gorelik M, Langford CA, Maz M, Abril A, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot M, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Polyarteritis Nodosa. Arthritis Care Res (Hoboken) 2021; 73:1061-1070. [PMID: 34235889 DOI: 10.1002/acr.24633] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/13/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of systemic polyarteritis nodosa (PAN). METHODS Twenty-one clinical questions regarding diagnostic testing, treatment, and management were developed in the population, intervention, comparator, and outcome (PICO) format for systemic, non-hepatitis B-related PAN. Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence and formulate recommendations. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 16 recommendations and 1 ungraded position statement for PAN. Most recommendations were graded as conditional due to the paucity of evidence. These recommendations support early treatment of severe PAN with cyclophosphamide and glucocorticoids, limiting toxicity through minimizing long-term exposure to both treatments, and the use of imaging and tissue biopsy for disease diagnosis. These recommendations endorse minimizing risk to the patient by using established therapy at disease onset and identify new areas where adjunctive therapy may be warranted. CONCLUSION These recommendations provide guidance regarding diagnostic strategies, use of pharmacologic agents, and imaging for patients with PAN.
Collapse
Affiliation(s)
| | | | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
49
|
Martins-Martinho J, Dourado E, Khmelinskii N, Espinosa P, Ponte C. Localized Forms of Vasculitis. Curr Rheumatol Rep 2021; 23:49. [PMID: 34196889 PMCID: PMC8247627 DOI: 10.1007/s11926-021-01012-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 12/26/2022]
Abstract
Purpose of Review To provide an updated review on epidemiology, clinical manifestations, diagnostic assessment, treatment, and prognosis of localized vasculitis, following the 2012 Revised International Chapel Hill Consensus Conference Nomenclature on single-organ vasculitis. Recent Findings Localized, single-organ vasculitides encompass a group of rare conditions in which there is no evidence of concomitant systemic vasculitis. Most data on this topic derives from case reports and small case series. Although some aspects of these diseases, such as clinical manifestations and histologic findings, have already been extensively investigated, there is still a lack of robust data concerning the pathogenesis, epidemiology, and treatment. Summary Localized vasculitides may have a wide range of clinical features depending on the organ affected. The inflammatory process may have a multifocal/diffuse or unifocal distribution. Diagnosis is usually based on histopathology findings and exclusion of systemic vasculitis, which may frequently pose a challenge. Further research on treatment is warranted.
Collapse
Affiliation(s)
- Joana Martins-Martinho
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal. .,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
| | - Eduardo Dourado
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Nikita Khmelinskii
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Pablo Espinosa
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal
| | - Cristina Ponte
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal
| |
Collapse
|
50
|
Loudon KW, Parmar J, Jayne DRW, Jones RB. Aggressive vasculitis after lung transplantation for cystic fibrosis. Rheumatology (Oxford) 2021; 60:iii47-iii49. [PMID: 34137874 DOI: 10.1093/rheumatology/keab041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/08/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kevin W Loudon
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK.,Department of Medicine, MRC Laboratory of Molecular Biology, Molecular Immunity Unit, University of Cambridge, Cambridge, UK
| | - Jasvir Parmar
- Department of Respiratory Medicine and Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Rachel B Jones
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
| |
Collapse
|