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Reinberg C, Vingerhoets S, Pavlova O, Guenova E, Papadimitriou-Olivgeris M, Comte D. Cryoglobulinemic vasculitis triggered by Staphylococcus aureus endocarditis with chronic hepatitis C virus co-infection: a case report and literature review. Front Immunol 2024; 15:1385086. [PMID: 39076993 PMCID: PMC11284083 DOI: 10.3389/fimmu.2024.1385086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 06/25/2024] [Indexed: 07/31/2024] Open
Abstract
Infective endocarditis is a rare but life-threatening condition, occasionally linked to diverse immunologic manifestations, including mixed cryoglobulinemia. This can lead to cryoglobulinemic vasculitis, which has the potential for widespread organ damage. Although some cases have highlighted the relationship between infective endocarditis and cryoglobulinemic vasculitis, no comprehensive epidemiological evaluation or optimal treatment strategies have been advanced for such a combination. We present a case of methicillin-sensitive Staphylococcus aureus infective endocarditis associated with cryoglobulinemic vasculitis and conduct a literature review to compare management and outcomes in similar cases. Our patient presented with classical Meltzer's triad and mild renal involvement. Cryoimmunofixation confirmed type III cryoglobulinemia, and serum cytokines showed elevated IL-6 levels. The differential diagnosis included infective endocarditis and chronic active hepatitis C virus infection. Rapid symptom resolution after antibiotic treatment identified infective endocarditis as the likely cause of cryoglobulinemic vasculitis. Our case and review of the literature highlight that early identification of the cause of cryoglobulinemic vasculitis is crucial for selecting appropriate treatment and preventing recurrence or morbidity.
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Affiliation(s)
- Céline Reinberg
- Service of Internal Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Sébastien Vingerhoets
- Service of Infectious Diseases, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Olesya Pavlova
- Service of Dermatology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Emmanuella Guenova
- Service of Dermatology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | | | - Denis Comte
- Service of Internal Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Dashjamts G, Ganzorig AE, Tsedendorj Y, Dondov G, Nergui O, Badamjav T, Huang CF, Liang PC, Lonjid T, Batsaikhan B, Dai CY. Post-Treatment Occurrence of Serum Cryoglobulinemia in Chronic Hepatitis C Patients. Diagnostics (Basel) 2024; 14:1188. [PMID: 38893714 PMCID: PMC11171999 DOI: 10.3390/diagnostics14111188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Persistent cryoglobulinemia after the completion of antiviral treatment is an important consideration of clinical management in chronic hepatitis C patients. We aimed to investigate the occurrence of serum cryoglobulinemia in chronic hepatitis C patients without cryoglobulinemia at the initiation of antiviral treatment. METHODS In total, 776 patients without cryoglobulinemia were assessed for serum cryoglobulinemia after the completion of anti-HCV treatment. Serum cryoglobulinemia precipitation was assessed upon both the initiation and the completion of the treatment and analyzed for the clinical laboratory factors associated with chronic hepatitis C. RESULTS One hundred eighteen (118) patients were checked for serum cryo-precipitation after the completion of the treatment, and eight patients (4.6%) were positive for serum cryoglobulinemia. The patients who tested positive for cryoglobulinemia included a higher proportion of liver cirrhosis patients (4/50%, p = 0.033) and other organ cancer patients (5/62.5%, p = 0.006) than patients who showed no signs of cryoglobulinemia after treatment. In a multivariate analysis, liver cirrhosis (odds ratio [OR]-17.86, 95% confidence interval [95% CI]-1.79-177.35, p = 0.014) and other organ cancer (OR-25.17 95% CI-2.59-244.23, p = 0.005) were independently and significantly associated with positive cryoglobulinemia 3 months after antiviral treatment. CONCLUSIONS Three months after the antiviral DAA therapy had concluded, eight patients tested positive for cryoglobulinemia, representing a 6.7% prevalence. Liver cirrhosis and other organ cancer were independently and significantly associated with positive cryoglobulinemia after antiviral treatment. Further investigation into the causes of positive cryoglobulinemia after DAA antiviral therapy is warranted.
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Affiliation(s)
- Gantogtokh Dashjamts
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Amin-Erdene Ganzorig
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Yumchinsuren Tsedendorj
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Ganchimeg Dondov
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Otgongerel Nergui
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Tegshjargal Badamjav
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
- Department of Biological Sciences, School of Life Sciences, Inner Mongolia University, Hohhot 010031, China
| | - Chung-Feng Huang
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan; (C.-F.H.); (P.-C.L.)
- Department of Occupational and Environmental Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
| | - Po-Cheng Liang
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan; (C.-F.H.); (P.-C.L.)
- Department of Occupational and Environmental Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
| | - Tulgaa Lonjid
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
| | - Batbold Batsaikhan
- Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia; (G.D.); (A.-E.G.); (Y.T.); (G.D.); (O.N.); (T.B.); (T.L.)
- Department of Health Research, Graduate School, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia
| | - Chia-Yen Dai
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807378, Taiwan; (C.-F.H.); (P.-C.L.)
- Ph.D. Program in Environmental and Occupational Medicine, Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung 807378, Taiwan
- College of Professional Studies, National Pingtung University of Science and Technology, Pingtung 91201, Taiwan
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Lu H, Cui Z, Zhou XJ, Yang Y, Han XN, Li XH, Zhou FD, Zhao MH. Proteinase‑3‑antineutrophil cytoplasmic antibody‑associated vasculitis secondary to subacute infective endocarditis: A case report. Exp Ther Med 2024; 27:216. [PMID: 38590565 PMCID: PMC11000458 DOI: 10.3892/etm.2024.12504] [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: 06/10/2023] [Accepted: 02/02/2024] [Indexed: 04/10/2024] Open
Abstract
A 58-year-old male patient was admitted to Peking University First Hospital (Beijing, China) due to recurrent hematuria, proteinuria and kidney dysfunction. The patient was positive for proteinase-3 (PR3)-antineutrophil cytoplasmic antibody (ANCA). Pathology of the kidney showed focal proliferative necrotizing glomerulonephritis with crescent formation and immune complex-mediated glomerulonephritis. The patient was diagnosed with PR3-ANCA-associated vasculitis (AAV), received intensive immunosuppressive therapy and experienced two relapses within 1 year. After admission, aortic valve vegetation was observed via echocardiography. The patient subsequently received antibiotic treatment and valve replacement, and achieved complete remission of kidney and cardiac function. The present case emphasized the importance of identifying secondary reasons for ANCA formation, especially infective endocarditis in patients with PR3-AAV.
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Affiliation(s)
- Hui Lu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, P.R. China
- Institute of Nephrology, Peking University, Beijing 100034, P.R. China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, P.R. China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing 100034, P.R. China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing 100034, P.R. China
| | - Zhao Cui
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, P.R. China
- Institute of Nephrology, Peking University, Beijing 100034, P.R. China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, P.R. China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing 100034, P.R. China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing 100034, P.R. China
| | - Xu-Jie Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, P.R. China
- Institute of Nephrology, Peking University, Beijing 100034, P.R. China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, P.R. China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing 100034, P.R. China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing 100034, P.R. China
| | - Ying Yang
- Department of Cardiology, Peking University First Hospital, Beijing 100034, P.R. China
| | - Xiao-Ning Han
- Department of Cardiology, Peking University First Hospital, Beijing 100034, P.R. China
| | - Xi-Hui Li
- Department of Cardiac Surgery, Peking University First Hospital, Beijing 100034, P.R. China
| | - Fu-De Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, P.R. China
- Institute of Nephrology, Peking University, Beijing 100034, P.R. China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, P.R. China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing 100034, P.R. China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing 100034, P.R. China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, P.R. China
- Institute of Nephrology, Peking University, Beijing 100034, P.R. China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, P.R. China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing 100034, P.R. China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing 100034, P.R. China
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Ogrič M, Švec T, Poljšak KM, Lakota K, Podovšovnik E, Kolopp-Sarda MN, Hočevar A, Čučnik S. Insights into the immunological description of cryoglobulins with regard to detection and characterization in Slovenian rheumatological patients. Immunol Res 2024; 72:185-196. [PMID: 37993756 PMCID: PMC11031437 DOI: 10.1007/s12026-023-09434-9] [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: 09/29/2023] [Accepted: 11/06/2023] [Indexed: 11/24/2023]
Abstract
The detection of cryoglobulins (CG) used to diagnose cryoglobulinemic vasculitis requires strict adherence to protocol, with emphasis on the preanalytical part. Our main objectives were to introduce a more sensitive and specific protocol for the detection of CG and to characterize CG in Slovenian patients diagnosed with cryoglobulinemic vasculitis, other vasculitides, connective tissue diseases or non-rheumatic diseases examined at the Department of Rheumatology (University Medical Centre Ljubljana). Samples were routinely analyzed for the presence of CG with the protocol using the Folin-Ciocalteu reagent. In the newly introduced protocol, the type of CG was determined by immunofixation on visually observed positive samples and the concentration of CG in the cryoprecipitate and rheumatoid factor (RF) activity were measured by nephelometry. RF, C3c and C4 were measured in patients` serum and a decision tree analysis was performed using all results. The agreement between negative and positive results between the two protocols was 86%. Of the 258 patient samples tested, we found 56 patients (21.7%) with positive CG (37.5% - type II, 62.5% - type III). The RF activity was observed in 21.4% of CG positive subjects. The median concentration of type II CG was significantly higher than that of type III CG (67.4 mg/L vs. 45.0 mg/L, p = 0.037). Patients with type II had lower C4 concentrations and higher RF compared to patients with type III CG. In the decision tree, C4 was the strongest predictor of cryoglobulinemia in patients. With the newly implemented protocol, we were able to improve the detection and quantification of CG in the samples of our rheumatology patients and report the results to adequately support clinicians.
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Affiliation(s)
- Manca Ogrič
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tinka Švec
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Katjuša Mrak Poljšak
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Katja Lakota
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- FAMNIT, University of Primorska, Koper, Slovenia
| | | | - Marie Nathalie Kolopp-Sarda
- Immunogenomics and Inflammation Research, University of Lyon, Lyon, France
- Immunology Laboratory, University Hospital Lyon, Lyon, France
| | - Alojzija Hočevar
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Saša Čučnik
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia.
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia.
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Nakagawa N, Fujii A, Ueda Y, Yamazaki M. Cryoglobulinemia vasculitis associated with adult-onset Still's disease. Clin Case Rep 2024; 12:e8632. [PMID: 38455857 PMCID: PMC10918707 DOI: 10.1002/ccr3.8632] [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: 12/11/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/09/2024] Open
Abstract
Key Clinical Message The present case indicates that cryoglobulinemia vasculitis should be considered in the differential diagnosis of purpura in patients with adult-onset Still's disease (AOSD). Abstract The presence of purpura is suggested in adult-onset Still's disease (AOSD) hematological complications of hemophagocytic syndrome, disseminated intravascular coagulation, or thrombotic microangiopathy. We herein report a case of AOSD complicated by cryoglobulinemia vasculitis presenting with purpura.
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Affiliation(s)
- Noriharu Nakagawa
- Department of Internal MedicineKeiju Medical CenterNanaoIshikawaJapan
| | - Ai Fujii
- Department of Internal MedicineKeiju Medical CenterNanaoIshikawaJapan
- Department of NephrologyKanazawa Medical UniversityKahokuIshikawaJapan
| | - Yoshimichi Ueda
- Department of PathologyKeiju Medical CenterNanaoIshikawaJapan
| | - Masahide Yamazaki
- Department of Internal MedicineKeiju Medical CenterNanaoIshikawaJapan
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6
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Granata G, Tomasello F, Sciarrone MA, Stifano V, Lauretti L, Luigetti M. Neuralgic Amyotrophy and Hourglass Nerve Constriction/Nerve Torsion: Two Sides of the Same Coin? A Clinical Review. Brain Sci 2024; 14:67. [PMID: 38248282 PMCID: PMC10813384 DOI: 10.3390/brainsci14010067] [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: 11/29/2023] [Revised: 12/29/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
Neuralgic amyotrophy, also called Parsonage-Turner syndrome, in its classic presentation is a brachial plexopathy or a multifocal neuropathy, involving mainly motor nerves of the upper limb with a monophasic course. Recently, a new radiological entity was described, the hourglass constriction, which is characterized by a very focal constriction of a nerve, or part of it, usually associated with nerve thickening proximally and distally to the constriction. Another condition, which is similar from a radiological point of view to hourglass constriction, is nerve torsion. The pathophysiology of neuralgic amyotrophy, hourglass constriction and nerve torsion is still poorly understood, and a generic role of inflammation is proposed for all these conditions. It is now widely accepted that nerve imaging is necessary in identifying hourglass constrictions/nerve torsion pre-surgically in patients with an acute mononeuropathy/plexopathy. Ultrasound and MRI are useful tools for diagnosis, and they are consistent with intraoperative findings. The prognosis is generally favorable after surgery, with a high rate of good motor recovery.
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Affiliation(s)
- Giuseppe Granata
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.G.); (V.S.); (L.L.)
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.T.); (M.A.S.)
| | - Fabiola Tomasello
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.T.); (M.A.S.)
| | - Maria Ausilia Sciarrone
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.T.); (M.A.S.)
| | - Vito Stifano
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.G.); (V.S.); (L.L.)
| | - Liverana Lauretti
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.G.); (V.S.); (L.L.)
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.T.); (M.A.S.)
| | - Marco Luigetti
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.G.); (V.S.); (L.L.)
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.T.); (M.A.S.)
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7
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Ponomarev AB, Pashayeva KR, Feyziyeva NY. [Comparative analysis of the development mechanisms of cryoglobulinemic vasculitis and Sjögren's syndrome]. Arkh Patol 2024; 86:52-56. [PMID: 38319273 DOI: 10.17116/patol20248601152] [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: 02/07/2024]
Abstract
Cryoglobulinemic vasculitis is a disease characterized by damage of small vessels and in some cases can be a manifestation of mixed cryoglobulinemia. Mixed cryoglobulinemia is a condition in which immunoglobulins in the blood serum form precipitates at temperatures below 37 °C and dissolve again when it rises. Currently, hepatitis C (HCV) is considered the most common etiological factor of mixed cryoglobulinemia. In addition, mixed cryoglobulinemia may be associated with other infectious agents, as well as autoimmune and lymphoproliferative diseases. In the absence of such association, we can talk about essential mixed cryoglobulinemia. To understand how different nosologies in their clinical and morphological picture lead to the development of mixed cryoglobulinemia, it is necessary to carefully analyze the mechanisms of the development of some of them, namely, HCV-associated cryoglobulinemic vasculitis and Sjögren's syndrome. It is noteworthy that mixed cryoglobulinemia in relation to Sjögren's syndrome can be perceived both as its consequence and as a manifestation of the underlying disease. Such an ambiguous nature of mixed cryoglobulinemia makes it currently impossible to select clear diagnostic criteria. For this reason, it is necessary to carry out a comparison between different immunopathogenesis of mixed cryoglobulinemia in order to identify the features that form its classical manifestations.
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Affiliation(s)
- A B Ponomarev
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - K R Pashayeva
- The Baku Branch, I.M. Sechenov First Moscow State Medical University, Baku, Azerbaijan
| | - N Yu Feyziyeva
- The Baku Branch, I.M. Sechenov First Moscow State Medical University, Baku, Azerbaijan
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Yokoyama K, Kino T, Nagata T, Miyayama T, Shibata K, Fukuda H, Yamauchi R, Fukunaga A, Umeda K, Takata K, Tanaka T, Shakado S, Sakisaka S, Imafuku S, Hirai F. Hepatitis C Virus-associated Cryoglobulinemic Livedo Reticularis Improved with Direct-acting Antivirals. Intern Med 2023; 62:3631-3636. [PMID: 37121750 PMCID: PMC10781547 DOI: 10.2169/internalmedicine.1671-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/07/2023] [Indexed: 05/02/2023] Open
Abstract
We herein report a case of hepatitis C virus (HCV)-associated cryoglobulinemic livedo reticularis in a woman in her 60s that improved with direct-acting antivirals (DAAs). Hyperpigmentation was observed in both lower legs, and a skin biopsy confirmed livedo reticularis, suggesting a relationship with cryoglobulinemia and HCV infection. DAAs with an NS5A inhibitor+NS3/4A protease inhibitor (glecaprevir/pibrentasvir) were administered for eight weeks, and a sustained virological response (SVR) was obtained. The disappearance of serum cryoglobulin was confirmed approximately two years after an SVR was obtained and livedo reticularis was improved. DAA therapy can be an effective therapeutic option for extrahepatic complications associated with HCV infection.
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Affiliation(s)
- Keiji Yokoyama
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Tomohiro Kino
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Takahiro Nagata
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Takashi Miyayama
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Kumiko Shibata
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Hiromi Fukuda
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Ryo Yamauchi
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Atsushi Fukunaga
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Kaoru Umeda
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Kazuhide Takata
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Takashi Tanaka
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Satoshi Shakado
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Shotaro Sakisaka
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Shinichi Imafuku
- Department of Dermatology, Fukuoka University Faculty of Medicine, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
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9
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Miao J, Krisanapan P, Tangpanithandee S, Thongprayoon C, Cheungpasitporn W. Efficacy of Therapeutic Apheresis for Cryoglobulinemic Vasculitis Patients with Renal Involvement: A Systematic Review. Blood Purif 2023; 53:1-9. [PMID: 37852193 DOI: 10.1159/000534102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/10/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Therapeutic apheresis (TA) is commonly used for cryoglobulinemic vasculitis (CV) patients, but its efficacy remains uncertain. This systematic review aimed to assess the efficacy of different TA modalities, such as plasma exchange (PE), plasmapheresis (PP), and cryofiltration (CF), in treating CV patients with renal involvement. METHODS Literature search of MEDLINE, EMBASE, and Cochrane Databases was conducted up to December 2022. Studies that reported the outcomes of TA in adult CV patients with renal involvement were assessed. The protocol for this systematic review has been registered with PROSPERO (No. CRD42023417727). The quality of each study was evaluated by the investigators using the validated methodological index for non-randomized studies (minors) quality score. RESULTS 154 patients who encountered 170 episodes of serious events necessitating TA were evaluated across 76 studies. Among them, 51% were males, with a mean age ranging from 49 to 58 years. The CV types included 15 type I, 97 type II, and 13 type III, while the remaining patients exhibited mixed (n = 17) or undetermined CV types (n = 12). Among the treatment modalities, PE, PP, and CF were performed in 85 (56%), 52 (34%), and 17 patients (11%), respectively, with no identical protocol for TA treatment. The overall response rate for TA was 78%, with response rates of 84%, 77%, and 75% observed in type I, II, and III patients respectively. Most patients received steroids, immunosuppressants, and treatment targeting the underlying causative disease. The overall long-term renal outcome rate was 77%, with type I, II, and III patients experiencing response rates of 89%, 76%, and 90%, respectively. The renal outcomes in patients receiving PE, PP, and CF were comparable, with rates of 78%, 76%, and 81%, respectively. CONCLUSIONS This study presents compelling evidence that combination of TA with other treatments, especially immunosuppressive therapy, is a successful strategy for effectively managing severe renal involvement in CV patients. Among the TA modalities studied, including PE, PP, and CF, all demonstrated efficacy, with PE being the most frequently employed approach.
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Affiliation(s)
- Jing Miao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA,
| | - Pajaree Krisanapan
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
- Division of Nephrology, Department of Internal Medicine, Thammasat University Hospital, Pathum Thani, Thailand
| | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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10
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Roma K, Chandler TM, Dossaji Z, Patel A, Gupta K, Minacapelli CD, Rustgi V, Gish R. A Review of the Systemic Manifestations of Hepatitis B Virus Infection, Hepatitis D Virus, Hepatocellular Carcinoma, and Emerging Therapies. GASTRO HEP ADVANCES 2023; 3:276-291. [PMID: 39129946 PMCID: PMC11308766 DOI: 10.1016/j.gastha.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/26/2023] [Indexed: 08/13/2024]
Abstract
Chronic hepatitis B virus (HBV) infection affects about 262 million people worldwide, leading to over 820,000 deaths each year primarily due to cirrhosis and hepatocellular carcinoma. The World Health Organization has pledged to eliminate HBV as a health threat by 2030, but currently, no countries are on track to achieve this goal. One of the barriers to HBV elimination is stigma, causing shame, denial, self-isolation, self-rejection, and depression leading to those with chronic HBV less likely to get tested or seek treatment and more likely to conceal their infection. Other barriers include limited access to care and complicated and restrictive clinical practice guidelines. Increasing public and political efforts are necessary to raise awareness, increase access to care, and change screening and treatment guidelines. The current guidance of the American Association for the Study of Liver Diseases (AASLD) recommends testing only if patients are considered at risk, but this has proven to be ineffective. We propose a simplified "test all and treat all" approach with a 5-line guideline for HBV infection. Universal screening and treatment of adults is cost-effective and can prevent transmission by effectively managing chronic HBV. All patients who are hepatitis B surface antigen (HBsAg) positive with detectable HBV-DNA should receive treatment until HBsAg is undetectable for 12 months, as HBV-DNA transmission via blood transfusion can occur even at low viral loads of 16 copies/mL, and mother-to-child transmission is still a risk even with passive-active immunoprophylaxis. Furthermore, clinical outcomes after HBsAg clearance are significantly better than the clinical outcomes of those who remain HBsAg positive.
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Affiliation(s)
- Katerina Roma
- Internal Medicine, Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Nevada
| | - Toni-Marie Chandler
- Division of Gastroenterology and Hepatology, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), New Brunswick, New Jersey
| | - Zahra Dossaji
- Internal Medicine, Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Nevada
| | - Ankoor Patel
- Internal Medicine, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, New Jersey
| | - Kapil Gupta
- Division of Gastroenterology and Hepatology, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), New Brunswick, New Jersey
| | - Carlos D. Minacapelli
- Division of Gastroenterology and Hepatology, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), New Brunswick, New Jersey
- Center for Liver Diseases and Masses, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), New Brunswick, New Jersey
| | - Vinod Rustgi
- Division of Gastroenterology and Hepatology, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), New Brunswick, New Jersey
- Center for Liver Diseases and Masses, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), New Brunswick, New Jersey
| | - Robert Gish
- Hepatitis B Foundation, Doylestown, Pennsylvania
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11
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Aw YTV, McGuane JT. Cutaneous leukocytoclastic vasculitis associated with verapamil and atorvastatin: A case report. Clin Case Rep 2023; 11:e7683. [PMID: 37469372 PMCID: PMC10352572 DOI: 10.1002/ccr3.7683] [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: 04/13/2023] [Revised: 06/08/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023] Open
Abstract
We report a case of biopsy-proven cutaneous leukocytoclastic vasculitis developing 10 days after starting verapamil and atorvastatin in a patient with long-standing Sjogren's syndrome. This highlights the need to monitor for this rare adverse effect.
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Affiliation(s)
- Yi Tong Vincent Aw
- General Medicine Department, Canberra HospitalCanberra Health ServicesCanberraAustralia
- Australian National University Medical SchoolAustralian National UniversityCanberraAustralia
| | - Jonathan Thomas McGuane
- Australian National University Medical SchoolAustralian National UniversityCanberraAustralia
- ACT Pathology, Canberra HospitalCanberra Health ServicesCanberraAustralia
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12
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Yang X, Jiao C, Liu X, Zhang Y, Zhou H, Wang Y. Coexistence of cryoglobulinemia and ANCA-associated vasculitis in a chronic brucellosis patient -a case report and literature review. BMC Infect Dis 2023; 23:272. [PMID: 37131122 PMCID: PMC10152744 DOI: 10.1186/s12879-023-08232-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/06/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND The renal involvement of brucellosis is not common. Here we reported a rare case of chronic brucellosis accompanied by nephritic syndrome, acute kidney injury, the coexistence of cryoglobulinemia and antineutrophil cytoplasmic autoantibodies (ANCA) associated vasculitis (AAV) superimposed on iliac aortic stent implantation. The diagnosis and treatment of the case are instructive. CASE PRESENTATION A 49-year-old man with hypertension and iliac aortic stent implantation was admitted for unexplained renal failure with signs of nephritic syndrome, congestive heart failure, moderate anemia and livedoid change in the left sole with pain. His past history included chronic brucellosis and he just underwent the recurrence and completed the 6 weeks of antibiotics treatment. He demonstrated positive cytoplasmic/proteinase 3 ANCA, mixed type cryoglobulinemia and decreased C3. The kidney biopsy revealed endocapillary proliferative glomerulonephritis with a small amount of crescent formation. Immunofluorescence staining revealed only C3-positive staining. In accordance with clinical and laboratory findings, post-infective acute glomerulonephritis superimposed with AAV was diagnosed. The patient was treated with corticosteroids and antibiotics and sustained alleviation of renal function and brucellosis was achieved during the course of a 3-month follow-up. CONCLUSIONS Here we describe the diagnostic and treatment challenge in a patient with chronic brucellosis related glomerulonephritis accompanied by the coexistence of AAV and cryoglobulinemia. Renal biopsy confirmed the diagnosis of postinfectious acute glomerulonephritis overlapping with ANCA related crescentic glomerulonephritis, which was not ever reported in the literature. The patient showed a good response to steroid treatment which indicated the immunity-induced kidney injury. Meanwhile, it is essential to recognize and actively treat the coexisting brucellosis even when there are no clinical signs of the active stage of infection. This is the critical point for a salutary patient outcome for brucellosis associated renal complications.
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Affiliation(s)
- Xu Yang
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Congcong Jiao
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Xiaomei Liu
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Yongzhe Zhang
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Hua Zhou
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China
| | - Yanqiu Wang
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, China.
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13
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Stoyanov A, Toong C, Kong Y, Chen R, Urriola N. Serum protein electrophoresis and rheumatoid factor analysis is an effective screening strategy for cryoglobulinaemia. Pathology 2023; 55:391-396. [PMID: 36494206 DOI: 10.1016/j.pathol.2022.09.004] [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: 04/22/2022] [Revised: 08/05/2022] [Accepted: 09/06/2022] [Indexed: 11/15/2022]
Abstract
Accurate serum cryoglobulin detection is important to allow prompt treatment but laboratory testing requires stringent pre-analytical conditions and has long turnaround times. Serum protein electrophoresis (EPG) for paraproteinaemia and rheumatoid factor (RF) analysis may offer an effective initial screening strategy for the presence of cryoglobulinaemia. We retrospectively assessed the sensitivity of ancillary EPG and RF testing for the presence of serum cryoglobulinaemia in 586 eligible cryoglobulin positive samples received at the Royal Prince Alfred and Liverpool Hospital immunopathology laboratories over an 11-year period. Ninety-one percent of all cryoglobulin positive samples had either a detectable paraprotein or RF activity, with greatest sensitivity for type I and type II cryoglobulins (97% and 98%, respectively). The sensitivity remained high irrespective of whether EPG and RF analysis was performed with the same, or different, pre-analytical collection conditions to the cryoglobulin collection (92% vs 90%, p=0.46). Only two patients with detected cryoglobulins and no associated paraprotein or RF activity had clinical features of cryoglobulinaemia and neither required treatment. This study demonstrates that serum EPG and RF analysis has high sensitivity for the detection of clinically relevant cryoglobulinaemia, even when not collected under ideal pre-analytical conditions, and potentially offers a prompt and effective screening strategy.
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Affiliation(s)
- Alex Stoyanov
- Central Sydney Immunopathology Laboratory, Pathology East, NSW Health Pathology, Sydney, NSW, Australia.
| | - Catherine Toong
- Department of Immunopathology, Liverpool Hospital, NSW Health Pathology, Sydney, NSW, Australia
| | - Yvonne Kong
- Department of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Renfen Chen
- Central Sydney Immunopathology Laboratory, Pathology East, NSW Health Pathology, Sydney, NSW, Australia
| | - Nicolás Urriola
- Department of Clinical Immunology, Royal Prince Alfred Hospital, Sydney, Australia
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14
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Ishizu A, Kawakami T, Kanno H, Takahashi K, Miyazaki T, Ikeda E, Oharaseki T, Ogawa Y, Onimaru M, Kurata M, Nakazawa D, Muso E, Harigai M. Expert perspectives on pathological findings in vasculitis. Mod Rheumatol 2023; 33:1-11. [PMID: 35535676 DOI: 10.1093/mr/roac043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/30/2022] [Accepted: 05/03/2022] [Indexed: 01/05/2023]
Abstract
Pathological findings are important in the diagnosis of vasculitis. However, due to the rarity of the disease, standard textbooks usually devote only a few pages to this topic, and this makes it difficult for clinicians not specializing in vasculitis to fully understand the pathological findings in vasculitis. To address the paucity of information, we present representative pathological findings in vasculitis classified in the 2012 Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides (CHCC2012). The CHCC2012 classifies 26 vasculitides into seven categories: (1) large-vessel vasculitis, (2) medium-vessel vasculitis, (3) small-vessel vasculitis, including antineutrophil cytoplasmic antibody-associated vasculitis and immune complex small-vessel vasculitis, (4) variable-vessel vasculitis, (5) single-organ vasculitis, (6) vasculitis associated with systemic disease, and (7) vasculitis associated with probable aetiology. Moreover, representative pathological findings of vasculitis-related diseases and non-inflammatory vasculopathy not mentioned in the CHCC2012 are also presented. This will be useful for clinicians to refer to typical pathological findings of vasculitis in daily practice.
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Affiliation(s)
- Akihiro Ishizu
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Tamihiro Kawakami
- Division of Dermatology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Hiroyuki Kanno
- Department of Pathology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kei Takahashi
- Department of Pathology, Toho University Ohashi Medical Center, Tokyo, Japan
| | | | - Eiji Ikeda
- Department of Pathology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Toshiaki Oharaseki
- Department of Pathology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yayoi Ogawa
- Hokkaido Renal Pathology Center, Sapporo, Japan
| | - Mitsuho Onimaru
- Division of Pathophysiological and Experimental Pathology, Department of Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mie Kurata
- Department of Analytical Pathology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Daigo Nakazawa
- Department of Rheumatology, Endocrinology, and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Eri Muso
- Department of Nephrology and Dialysis, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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15
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Auanassova A, Yessirkepov M, Zimba O, Gasparyan AY, Joshi M, Agarwal V, Kitas GD, Ahmed S. Physicians' perceptions about antineutrophil cytoplasmic antibody-associated vasculitis: an online survey report in the time of the COVID-19 pandemic. Clin Rheumatol 2023; 42:831-837. [PMID: 36414862 PMCID: PMC9684751 DOI: 10.1007/s10067-022-06452-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/23/2022]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are characterized by necrotizing inflammation of small and medium-size vessels that often manifest with devastating multi-organ effects. They present with a myriad of systemic features and require potent immunosuppression. Since they are uncommonly encountered in clinical practice, it is necessary to understand physicians' knowledge and perceptions about this group of diseases. An online questionnaire was designed featuring 28 questions based on relevant global practice guidelines, recommendations, and previous online surveys on AAV. The questionnaire was validated by a core group of specialists with an interest in AAV. It was shared via social networking sites and entries were restricted to physicians. Only completed entries were analyzed with descriptive statistics. A total of 113 respondents from 21 different countries responded of whom the commonest were rheumatologists, internists, and general practitioners. Forty-five (40%) ran clinics dedicated to AAV patients as a part of their practice. They commented on organs involved in AAV; vasculitis secondary to infections, drugs or other rheumatic diseases; various tests useful for AAV diagnosis; and drug choices for induction and maintenance. They mentioned their experience regarding COVID-19 in AAV patients as well as vasculitic manifestations of COVID-19. Various methods to mitigate cardiovascular risks in AAV were mentioned. Finally, the respondents indicated how medical education needed to be strengthened to increase awareness and knowledge regarding AAV. This survey helped to inform about various perceptions regarding AAV across countries, including current practices and recent evolution of management. It also provided information on treatment of the COVID-19 in AAV patients. This survey showed that there is still a lack in understanding the prevalent definitions and there is gap between guidelines and current practice. Key Points • Perception about ANCA-associated vasculitis differ across countries. • The number of cases encountered across 21 different countries are limited implying a need for multi-national cooperation to study this disease further. • The COVID-19 pandemic has changed the approach towards ANCA-associated vasculitis by the various clinicians.
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Affiliation(s)
- Akerke Auanassova
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Marlen Yessirkepov
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Olena Zimba
- Department of Internal Medicine #2, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Armen Yuri Gasparyan
- Departments of Rheumatology and Research and Development, Dudley Group NHS Foundation Trust (Teaching Trust of the University of Birmingham, UK), Russells Hall Hospital, Dudley, West Midlands UK
| | - Mrudula Joshi
- Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospitals, Pune, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
| | - George D. Kitas
- Departments of Rheumatology and Research and Development, Dudley Group NHS Foundation Trust (Teaching Trust of the University of Birmingham, UK), Russells Hall Hospital, Dudley, West Midlands UK ,Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
| | - Sakir Ahmed
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. .,Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, 751024, India.
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16
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Fornero L, Kanouni T, Tudesq JJ, Pochard C, Verot P, Renier W, Gabellier L, Cartron G, Guilpain P, Herbaux C. Preventive plasmapheresis for rituximab related flare in cryoglobulinemic vasculitis. J Transl Autoimmun 2023; 6:100194. [PMID: 36874399 PMCID: PMC9975310 DOI: 10.1016/j.jtauto.2023.100194] [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: 02/05/2023] [Accepted: 02/10/2023] [Indexed: 02/13/2023] Open
Abstract
Introduction Rituximab monotherapy represents the main therapeutic option for cryoglobulinemic vasculitis (CV) with severe organ involvement. However, initial worsening of the CV, known as rituximab-associated CV flare (=CV flare), has been described and are associated with high mortality rates. The aim of the present study is to evaluate the outcomes of plasmapheresis initiated before or during rituximab treatment, as prevention of CV flare. Methods We conducted a retrospecttive study in our tertiary referral center from 2001 to 2020. We have included all patients with CV receiving rituximab and divided them in two groups whether they had flare prevention by plasmapheresis or not. We evaluated rituximab-related CV flare incidence in both groups. CV flare was defined as the onset of a new organ involvement or worsening of the initial manifestations within 4 weeks following rituximab. Results Among the 71 patients included, 44 received rituximab without plasmapheresis (control = CT cohort) and 27 received plasmapheresis before or during rituximab treatment (preventive plasmapheresis = PP cohort). PP was given to patients thought to have a high risk of CV flare, with significantly more severe diseases than patients in the CT cohort. Despite this, no CV flare was observed in the PP group. In the other hand, 5 flares occurred in the CT cohort. Conclusion Our results show that plasmapheresis is efficient and well tolerated to prevent rituximab-associated CV flare. We believe that our data support the use of plasmapheresis in this indication, especially in patients with high risk of CV flare.
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Affiliation(s)
- Léa Fornero
- CHRU Montpellier: Hématologie Clinique, France
| | | | | | | | | | | | | | | | - Philippe Guilpain
- CHRU Montpellier: Médecine Interne et Maladies Multi-organiques, France
| | - Charles Herbaux
- CHRU Montpellier: Hématologie Clinique, France.,CNRS UMR 9002 - Institute of Human Genetics, France
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17
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Ly S, Nedosekin D, Wong HK. Review of an Anti-CD20 Monoclonal Antibody for the Treatment of Autoimmune Diseases of the Skin. Am J Clin Dermatol 2023; 24:247-273. [PMID: 36630066 PMCID: PMC9838371 DOI: 10.1007/s40257-022-00751-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 01/12/2023]
Abstract
Biologic therapies targeting B-cells are emerging as an effective strategy to treat a variety of immune-mediated diseases. One of the most studied B-cell-targeted therapies is rituximab, an anti-CD20 monoclonal antibody that exemplifies B-cell depletion therapy and has served as the prototype for other anti-CD20 monoclonal antibodies and the development of biosimilars. While there are multiple studies on the use of rituximab in dermatology, a comprehensive review of rituximab therapy in autoimmune skin conditions is lacking. In this literature review, we summarize indications, treatment efficacy, and safety of rituximab among common autoimmune diseases of the skin: pemphigus vulgaris, cutaneous lupus erythematous, dermatomyositis, systemic sclerosis, thyroid dermopathy, autoimmune pemphigoid diseases, and cutaneous vasculitis diseases. Existing data on rituximab support the approach of rituximab, biosimilars, and newer B-cell-targeting therapies in immune-mediated cutaneous diseases. Overall, rituximab, which targets CD20, provides an effective alternative or concomitant option to traditional immunosuppressants in the management of various autoimmune diseases of the skin. Further studies are necessary to expand the understanding and possible utility of B-cell-targeted therapies among autoimmune skin diseases.
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Affiliation(s)
- Sophia Ly
- grid.241054.60000 0004 4687 1637College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Dmitry Nedosekin
- grid.241054.60000 0004 4687 1637College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Henry K. Wong
- grid.241054.60000 0004 4687 1637Department of Dermatology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot #576, Little Rock, AR 72205 USA
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18
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Muacevic A, Adler JR, Verma N. An Unusual Presentation of Cryoglobulinemia in a Patient With Undiagnosed Sjögren's Syndrome and Treated Marginal Zone Lymphoma. Cureus 2022; 14:e32730. [PMID: 36686139 PMCID: PMC9851851 DOI: 10.7759/cureus.32730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
Our case details a 47-year-old female who presented to our cancer hospital with a petechial rash of the lower extremities as well as a headache and blurred vision for the prior two days. She was found to have systolic pressures in the 200s in the emergency department and was admitted for a hypertensive emergency. Notable medical history includes marginal zone lymphoma (MZL) status post-submandibular resection at an outside institution in 11/2017 (thought to be in remission). With her history in mind, she also reported subjective submandibular swelling on admission and an unintentional 25-pound weight loss over the eight weeks prior to admission. A PET scan was completed, which showed diffusely increased reticuloendothelial activity, and a follow-up bone marrow biopsy was without residual lymphoma activity. Creatinine was markedly elevated with significant proteinuria, and a renal biopsy revealed thrombotic microangiopathy, acute tubular injury, and moderate interstitial fibrosis. Remarkable laboratory tests included positive quantitative cryoglobulins ("cryocrit") and low complement 4 (C4). Qualitative cryoglobulins were never obtained, unfortunately. She was started on prednisone and transferred to a nearby academic hospital for formal rheumatologic evaluation. Importantly, testing at this facility showed elevated Sjögren's syndrome-related antigen A (SSA/Ro) antibodies. Also elicited at the academic hospital was that she had been experiencing symptoms of chronic dry eyes and mouth years even before her diagnosis of MZL. She was diagnosed with primary Sjögren's syndrome, which was thought to be the cause of her likely mixed cryoglobulinemia and the precipitant of her acute renal failure with hypertensive emergency, her skin changes, her anemia, and her hypocomplementemia. Of note, prior to discharge from the academic hospital, the patient's cryoglobulin testing was negative after prolonged steroid treatment, and she was placed on rituximab for maintenance. Our case is important as it helps illustrate one of the myriad precipitants of mixed cryoglobulinemia, in this case possibly untreated Sjögren's syndrome.
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19
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Xu W, Han Y. Hepatitis B virus-associated cryoglobulinaemia diffuse endocapillary proliferative glomerulonephritis: a case report and literature review. J Int Med Res 2022; 50:3000605221131136. [PMID: 36345172 PMCID: PMC9647261 DOI: 10.1177/03000605221131136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 09/09/2022] [Indexed: 08/30/2023] Open
Abstract
Cryoglobulinaemia can manifest as fatigue, purpura, and joint pain, and can involve the kidneys and peripheral nervous system. Type II and mixed cryoglobulinemia cases are usually associated with hepatitis C virus infection and autoimmune diseases, and most cases reported outside China have been related to hepatitis C virus. The pathological manifestation of cryoglobulinaemia glomerulonephritis is always membranous proliferative glomerulonephritis or membranous nephropathy; other pathological types are rare. This current case report describes a female patient with hepatitis B virus (HBV)-associated cryoglobulinaemic glomerulonephritis. The patient had hepatitis B complicated with purpura, abnormal urinalysis and renal function. She was positive for rheumatoid factor and had decreased complement, and her blood cryoglobulin level was positive. The pathological findings were consistent with late-stage capillary proliferative glomerulonephritis, which improved after steroid, immunosuppressant and anti-HBV treatment.
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Affiliation(s)
- Weiying Xu
- Department of Rheumatology, Sir Run Run Shaw
Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang
Province, China
| | - Yongmei Han
- Department of Rheumatology, Sir Run Run Shaw
Hospital, School of Medicine, Zhejiang University, Hangzhou City, Zhejiang
Province, China
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20
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Pavlovich SS, Bennett WC, Terinte-Balcan G, Hladik G, Jain K. Infective Endocarditis-Associated Pauci-Immune Glomerulonephritis in a Patient With Cryoglobulinemia. Cureus 2022; 14:e27560. [PMID: 36059292 PMCID: PMC9428425 DOI: 10.7759/cureus.27560] [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: 07/30/2022] [Indexed: 11/17/2022] Open
Abstract
Small-vessel vasculitis has a broad differential with similar clinical presentation and laboratory abnormalities, including petechial rashes, neurologic symptoms, glomerulonephritis, and abnormal inflammatory markers. Biopsy-based diagnosis is critical as the treatment varies by etiology. We report a case of a 41-year-old man with diagnosed cryoglobulinemia and hepatitis C presenting with a petechial rash, altered mental status, and acute kidney injury and ultimately found to have proteinase 3 (PR3)-antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis secondary to infective endocarditis. Skin biopsy was consistent with resolving, but nonspecific vasculitis and MRI showed foci of hemosiderin deposition concerning vasculitic lesions. Blood cultures grew Enterococcus faecalis, and he was treated with IV antibiotics. Kidney biopsy showed pauci-immune necrotizing focal segmental glomerulonephritis (GN) and diffuse acute tubular necrosis (ATN). After blood cultures cleared, he was initially treated with mycophenolate for worsening renal function. When the patient stopped antibiotics unexpectedly, his kidney function worsened and improved only after immunosuppression was stopped and antibiotics were restarted. This case highlights the importance of renal biopsy in patients with multiple potential etiologies of GN. The case resolution also reinforces that patients with infective endocarditis causing ANCA-associated GN should be treated with antibiotics in addition to, and possibly instead of, immunosuppression.
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21
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Zhang X, Yu XJ, An CW, Yong ZH, Wang SX, Zhou FD, Zhao MH. Clinicopathological Spectrum of Cryoglobulinemic Glomerulonephritis without Evidence of Autoimmunity Disorders: A Retrospective Study from a Single Institute of China. KIDNEY DISEASES (BASEL, SWITZERLAND) 2022; 8:253-263. [PMID: 35702704 PMCID: PMC9149548 DOI: 10.1159/000522537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/08/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Cryoglobulinemic glomerulonephritis (Cryo-GN), caused by circulating cryoglobulins, has varied etiology and clinical-pathologic manifestations. This study aimed to investigate the clinicopathological spectrum and outcome of patients with various Cryo-GN in China. METHODS A retrospective review of 74 Chinese patients with biopsy-proven cryoglobulin-related renal lesions in Peking University First Hospital from 2010 to 2020 was performed. RESULTS The mean age at diagnosis was 52.9 ± 15.0 years, and the female-to-male ratio was about 2/5. For the etiology screening, serum/urine monoclonal immunoglobulin could be detected on immunofixation electrophoresis in 34% of patients, including 6 patients who had hematological malignancies. Fifty-seven percent of patients had HBV infection, far more than HCV infection (5%). Ten percent of patients had other infections, and 27% of patients were classified as essential or idiopathic. Eleven out of the 15 patients with type II cryoglobulinemia had a consistent monotype of serum monoclonal immunoglobulins and monoclonal cryoprecipitate. The clinical manifestations were similar between various types of cryoglobulinemia. Hematuria, proteinuria, hypertension, anemia, and chronic renal insufficiency were the most common features. Fifty-three percent of patients presented with nephrotic syndrome, and 32% experienced acute kidney injury. Hypocomplementemia, serum-positive rheumatoid factor activity, and skin lesions were reported in 45%, 29%, and 28% of patients, respectively. After a median of 24 months follow-up, 18 patients reached end-stage kidney disease. The clone-targeted treatment could retard the renal deterioration compared with immunosuppressive therapy. CONCLUSIONS This was the largest single-center, clinicopathological retrospective study of Cryo-GN in China. Our data strongly support the association between monoclonal gammopathy and type II Cryo-GN. The renal responsive rate of immunosuppressant therapy is still suboptimal. The clone-targeted treatment shows promising effects in patients with type I or II Cryo-GN.
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Affiliation(s)
- Xin Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Renal Pathology Center, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Xiao-juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Renal Pathology Center, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Chong-wen An
- Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Zi-hao Yong
- Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Su-xia Wang
- Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Fu-de Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Renal Pathology Center, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Ming-hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Renal Pathology Center, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Peking-Tsinghua Center for Life Sciences, Beijing, China
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22
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Edmonds N, Mannschreck D, Flowers RH. A rare case of type II cryoglobulinemic vasculitis with renal and pulmonary involvement in a patient with underlying lymphoplasmacytic lymphoma. Int J Dermatol 2022; 62:e302-e303. [PMID: 35383893 DOI: 10.1111/ijd.16183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/03/2022] [Accepted: 03/11/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Nicole Edmonds
- Department of Dermatology, University of Virginia, Charlottesville, VA, USA
| | - Diana Mannschreck
- Department of Dermatology, University of Virginia, Charlottesville, VA, USA
| | - R Hal Flowers
- Department of Dermatology, University of Virginia, Charlottesville, VA, USA
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23
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Bastoni D, Poggiali E. Necrotic lesions of the hands. EMERGENCY CARE JOURNAL 2022. [DOI: 10.4081/ecj.2022.10425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
An 82-year-old man with a history of end-stage renal disease due to glomerulonephritis requiring haemodialysis, hepatitis C-related liver cirrhosis and hypertensive cardiomyopathy presented with painful and necrotic lesions of both his hands. He had no other symptoms. [...]
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Lavine N, Ohayon A, Mahroum N. Renal autoimmunity: The role of bacterial and viral infections, an extensive review. Autoimmun Rev 2022; 21:103073. [PMID: 35245692 DOI: 10.1016/j.autrev.2022.103073] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 02/27/2022] [Indexed: 02/08/2023]
Abstract
Autoimmunity is a process by which the loss of self-tolerance results in an immune attack against the body own tissues and organs. For autoimmunity to occur, various elements serving as triggers were described by which infections are considered one of the leading factors. In turn, renal involvement in autoimmune diseases, whether by an organ-specific attack, or as part of a systemic disease process, is well known. As bacterial and viral infections are considered to be common triggers for autoimmunity in general, we aimed to study their association with renal autoimmunity in particular. We performed an extensive search of the recent and relevant medical literature regarding renal autoimmunity syndromes such as infection-associated glomerulonephritis and vasculitis, associated with bacterial and viral infections. By utilizing PubMed and Google Scholar search engines, over 200 articles and case reports were reviewed. Among other mechanisms, direct infection of the renal parenchyma, molecular mimicry, induction of B-cells or secretion of superantigens, bacterial and viral pathogens were found to correlate with the development of renal autoimmunity. Nevertheless, this was not true for all pathogens, as some mimic autoimmune diseases and others show a surprisingly protective effect. The exact immunopathogenesis is yet to be determined, however. For conclusion, bacterial and viral infections are linked to renal autoimmunity by both direct damage and as mediators of systemic diseases. Further research particularly on the immunopathogenetic mechanisms of renal autoimmunity associated with infections is required.
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Affiliation(s)
- Noy Lavine
- St. George School of Medicine, University of London, London, UK; Zabludowicz Center for autoimmune diseases, Sheba Medical Center, Ramat-Gan, Israel.
| | - Aviran Ohayon
- St. George School of Medicine, University of London, London, UK; Zabludowicz Center for autoimmune diseases, Sheba Medical Center, Ramat-Gan, Israel
| | - Naim Mahroum
- Zabludowicz Center for autoimmune diseases, Sheba Medical Center, Ramat-Gan, Israel; International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
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25
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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
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26
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Hepatitis B Virus Infection and Extra-Hepatic Manifestations: A Systemic Disease. Am J Gastroenterol 2022; 117:253-263. [PMID: 34913875 DOI: 10.14309/ajg.0000000000001575] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 11/11/2021] [Indexed: 12/11/2022]
Abstract
People living with hepatitis B virus (HBV) chronic infection are exposed to high rates of liver complications including end-stage liver disease and hepatocellular carcinoma. Extrahepatic manifestations of HBV infection have long been underestimated. Several of these extrahepatic syndromes have been well described, including systemic vasculitides, glomerulonephritis, and cutaneous manifestations. Other manifestations have been more recently described such as hematological malignancies and neurological diseases. These extrahepatic manifestations are associated with significant morbidity and mortality. Although not completely understood, underlying mechanisms include HBV-induced local and systemic inflammation. Suppression of HBV replication usually improves extrahepatic manifestations. This review will discuss how HBV induces inflammation and the extrahepatic manifestations of HBV infection to guide clinical management.
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27
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Moretti R, Giuffrè M, Merli N, Caruso P, Di Bella S, Tiribelli C, Crocè LS. Hepatitis C Virus-Related Central and Peripheral Nervous System Disorders. Brain Sci 2021; 11:1569. [PMID: 34942871 PMCID: PMC8699483 DOI: 10.3390/brainsci11121569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 12/19/2022] Open
Abstract
Hepatitis C Virus (HCV), despite being a hepatotropic virus, is the causative agent of many systemic disorders, such as vasculitis, autoimmune diseases, lymphoproliferative disorders, and a broad spectrum of neurological and psychiatric manifestations. Although symptoms have been misdiagnosed or underdiagnosed, only recently, evidence of direct (inflammatory) or indirect (immune-mediated) HCV-dependent cerebral effects has been established. HCV infection can promote acute inflammatory response, pro-coagulative status and ischemic disorders, and neurodegeneration. These effects rely on cerebral HCV replication, possibly mediated by blood-brain barrier alterations. Further study is needed to better understand the HCV-related mechanisms of brain damage.
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Affiliation(s)
- Rita Moretti
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
| | - Mauro Giuffrè
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
| | - Nicola Merli
- Department Neurological Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Paola Caruso
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
| | - Stefano Di Bella
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
| | | | - Lory Saveria Crocè
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
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Hecker C, Welponer T, Herold M, Trinka E, Broussalis E, Killer-Oberpfalzer M. Update on treatment strategies for vasculitis affecting the central nervous system. Drug Discov Today 2021; 27:1142-1155. [PMID: 34838730 DOI: 10.1016/j.drudis.2021.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/11/2021] [Accepted: 11/18/2021] [Indexed: 11/16/2022]
Abstract
Vasculitis affecting the nervous system is a rare disease that can not only present with nonspecific initial symptoms, but also run a severe course without accurate treatment. Although improvements have been achieved, diagnosis of vasculitis remains challenging, because many classification criteria are unspecific or inconclusive with regard to central nervous system (CNS) manifestations. Currently, beside an isolated primary CNS vasculitis, several systemic types of vasculitis are known to affect the nervous system. In this review, we provide an overview of the pathophysiology, current therapeutic guidelines, and highlight novel treatment strategies for CNS vasculitis.
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Affiliation(s)
- Constantin Hecker
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria.
| | - Tobias Welponer
- Department of Dermatology and Allergology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Manfred Herold
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology, and Rheumatology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria; Neuroscience Institute, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Erasmia Broussalis
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
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29
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Sy-Go JPT, Thongprayoon C, Herrera Hernandez LP, Zoghby Z, Leung N, Manohar S. Rituximab-Associated Flare of Cryoglobulinemic Vasculitis. Kidney Int Rep 2021; 6:2840-2849. [PMID: 34805636 PMCID: PMC8589694 DOI: 10.1016/j.ekir.2021.08.024] [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: 06/21/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 12/03/2022] Open
Abstract
Background Patients with cryoglobulinemic vasculitis (CV) can develop disease flare after rituximab administration. The objective of our study was to describe the prevalence, clinical characteristics, predisposing factors, and outcomes of patients with rituximab-associated flare of CV. Methods We conducted a retrospective study in a tertiary referral center until March 25, 2020. Results Among 64 patients with CV who received rituximab therapy in our center, 14 (22%) developed disease flare. Median age was 67.5 years. Seven patients (50%) had type II CV and the other half had either type I (n = 6) or type III (n = 1). Twelve patients (86%) had an underlying B-cell lymphoproliferative disorder as the cause of their CV. CV flare occurred after a median time of 5.5 days (range: 2–8 days). The organ systems most involved were the skin (n = 10), kidneys (n = 5), and peripheral nerves (n = 3). Five patients (36%) developed acute kidney injury (AKI), 3 of whom presented with nephritic syndrome secondary to biopsy-proven membranoproliferative glomerulonephritis. Treatment was directed against the underlying disease in addition to supportive care. Patients who developed flare were more likely to have B-cell lymphoproliferative disorder as the underlying etiology of their CV (P = 0.03). Eight patients (57%) died after a median time of 27 months. Conclusions Rituximab-associated flare can occur in all types of CV, tends to arise approximately 2 days and less than 1 week after rituximab administration, and is more likely to happen in patients with an underlying B-cell lymphoproliferative disorder. It does not indicate treatment failure, and rituximab should not be abandoned altogether. AKI is a common manifestation, and mortality rate at 2 years is high.
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Affiliation(s)
- Janina Paula T Sy-Go
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Charat Thongprayoon
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Loren P Herrera Hernandez
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ziad Zoghby
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Leung
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.,Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sandhya Manohar
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
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30
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Latov N. Immune mechanisms, the role of complement, and related therapies in autoimmune neuropathies. Expert Rev Clin Immunol 2021; 17:1269-1281. [PMID: 34751638 DOI: 10.1080/1744666x.2021.2002147] [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] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Autoimmune neuropathies have diverse presentations and underlying immune mechanisms. Demonstration of efficacy of therapeutic agents that inhibit the complement cascade would confirm the role of complement activation. AREAS COVERED A review of the pathophysiology of the autoimmune neuropathies, to identify those that are likely to be complement mediated. EXPERT OPINION Complement mediated mechanisms are implicated in the acute and chronic neuropathies associated with IgG or IgM antibodies that target the Myelin Associated Glycoprotein (MAG) or gangliosides in the peripheral nerves. Antibody and complement mechanisms are also suspected in the Guillain-Barré syndrome and chronic inflammatory demyelinating neuropathy, given the therapeutic response to plasmapheresis or intravenous immunoglobulins, even in the absence of an identifiable target antigen. Complement is unlikely to play a role in paraneoplastic sensory neuropathy associated with antibodies to HU/ANNA-1 given its intracellular localization. In chronic demyelinating neuropathy with anti-nodal/paranodal CNTN1, NFS-155, and CASPR1 antibodies, myotonia with anti-VGKC LGI1 or CASPR2 antibodies, or autoimmune autonomic neuropathy with anti-gAChR antibodies, the response to complement inhibitory agents would depend on the extent to which the antibodies exert their effects through complement dependent or independent mechanisms. Complement is also likely to play a role in Sjogren's, vasculitic, and cryoglobulinemic neuropathies.
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Affiliation(s)
- Norman Latov
- Department of Neurology, Weill Cornell Medical College, New York, USA
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31
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Cardon M, Syed B, Krishnan C. Cryoglobulinemic Vasculitic Mononeuritis Multiplex in a Teenager. Pediatr Neurol 2021; 124:1-2. [PMID: 34416514 DOI: 10.1016/j.pediatrneurol.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/13/2021] [Accepted: 07/16/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Meeta Cardon
- Clinical Affiliate Faculty, The University of Texas at Austin, Dell Medical School, Austin, Texas; Assistant Professor, Department of Neurology, University of New Mexico, Albuquerque, New Mexico.
| | - Briana Syed
- College of Natural Sciences and McCombs School of Business, The University of Texas at Austin, Austin, Texas
| | - Chandra Krishnan
- Assistant Professor, Department of Pathology, The University of Texas at Austin, Dell Medical School, Dell Children's Medical School, Austin, Texas
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32
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Jung Y, Lee EE, Yeo J, Kim MH, Choi SR, Song YW. A Case of Overlap Syndrome of Systemic Sclerosis and Cryoglobulinemic Vasculitis With Central Nervous System Involvement. JOURNAL OF RHEUMATIC DISEASES 2021; 28:242-246. [PMID: 37476365 PMCID: PMC10324908 DOI: 10.4078/jrd.2021.28.4.242] [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: 02/15/2021] [Revised: 03/19/2021] [Accepted: 03/28/2021] [Indexed: 07/22/2023]
Abstract
Mixed cryoglobulinemic vasculitis (CV) is occasionally caused by autoimmune diseases including systemic sclerosis. Multiorgan involvement such as skin, kidney, and peripheral nerve involvement is common in mixed CV. However, central nervous system (CNS) involvement is extremely rare. Here, we report a case of overlap syndrome of limited cutaneous systemic sclerosis and mixed cryoglobulinemic vasculitis with CNS involvement. The neurologic deficits and systemic symptoms improved promptly after steroid and cyclophosphamide therapy.
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Affiliation(s)
- Youjin Jung
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eunyoung Emily Lee
- Division of Rheumatology, Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Korea
| | - Jina Yeo
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Hyeon Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Se Rim Choi
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yeong Wook Song
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Napodano C, Gulli F, Rapaccini GL, Marino M, Basile U. Cryoglobulins: Identification, classification, and novel biomarkers of mysterious proteins. Adv Clin Chem 2021; 104:299-340. [PMID: 34462057 PMCID: PMC7604189 DOI: 10.1016/bs.acc.2020.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Cryoglobulins consist of serum immunoglobulins that precipitate below 37°C and resolubilize upon warming. The clinical triad of cryoglobulinemia usually includes purpura, weakness, and arthralgia. Cryoglobulinemic syndrome, clinically defined as a systemic vasculitis, is associated with chronic infection with hepatitis C virus (HCV) and autoimmune disorders and can evolve into B-cell malignancies. While the current literature about HCV-associated cryoglobulinemia is not very limited, little is known about the immunologic and serologic profiles of affected patients. Therefore, comprehension of the pathogenetic mechanisms underlying cryoprecipitation could be very helpful. Due to the persistence of viral antigenic stimulation, biomarkers to use after the worsening progression of HCV infection to lymphoproliferative and/or autoimmune diseases are widely needed. Laboratory methods used to detect and characterize low concentrations of cryoprecipitates and immunotyping patterns could improve patient management. The most critical factor affecting cryoglobulin testing is that the pre-analytical phase is not fully completed at 37°C.
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Affiliation(s)
- Cecilia Napodano
- Dipartimento di Scienze Mediche e Chirurgiche, UOC Gastroenterologia Fondazione Policlinico Universitario "A. Gemelli" I.R.C.C.S., Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Gulli
- Laboratorio di Patologia Clinica, Ospedale Madre Giuseppina Vannini, Rome, Italy
| | - Gian Ludovico Rapaccini
- Dipartimento di Scienze Mediche e Chirurgiche, UOC Gastroenterologia Fondazione Policlinico Universitario "A. Gemelli" I.R.C.C.S., Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mariapaola Marino
- Dipartimento Di Medicina E Chirurgia Traslazionale, Istituto di Patologia Generale, Fondazione Policlinico Universitario "A. Gemelli" I.R.C.C.S., Università Cattolica del Sacro Cuore, Rome, Italy
| | - Umberto Basile
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" I.R.C.C.S., Università Cattolica del Sacro Cuore, Rome, Italy.
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Iinuma S, Takahashi C, Nagashima T, Ishida-Yamamoto A. Cryoglobulinemic vasculitis associated with multicentric Castleman disease. J Dermatol 2021; 48:e474-e475. [PMID: 34110036 DOI: 10.1111/1346-8138.16025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/30/2021] [Accepted: 05/24/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Shin Iinuma
- Department of Dermatology, Japanese Red Cross Kitami Hospital, Kitami, Japan
| | - Chiaki Takahashi
- Department of Dermatology, Japanese Red Cross Kitami Hospital, Kitami, Japan
| | - Takahiro Nagashima
- Department of Internal Medicine, Japanese Red Cross Kitami Hospital, Kitami, Japan
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Bizjak M, Košnik M, Terhorst-Molawi D, Dinevski D, Maurer M. Cold Agglutinins and Cryoglobulins Associate With Clinical and Laboratory Parameters of Cold Urticaria. Front Immunol 2021; 12:665491. [PMID: 33995398 PMCID: PMC8117240 DOI: 10.3389/fimmu.2021.665491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/19/2021] [Indexed: 11/15/2022] Open
Abstract
Mast cell-activating signals in cold urticaria are not yet well defined and are likely to be heterogeneous. Cold agglutinins and cryoglobulins have been described as factors possibly associated with cold urticaria, but their relevance has not been explained. We performed a single-center prospective cohort study of 35 cold urticaria patients. Cold agglutinin and cryoglobulin test results, demographics, detailed history data, cold stimulation test results, complete blood count values, C-reactive protein, total immunoglobulin E levels, and basal serum tryptase levels were analyzed. Forty six percent (n = 16) of 35 tested patients had a positive cold agglutinin test and 27% (n = 9) of 33 tested patients had a positive cryoglobulin test. Cold agglutinin positive patients, when compared to cold agglutinin negative ones, were mainly female (P = 0.030). No gender-association was found for cryoglobulins. A positive cold agglutinin test, but not a positive cryoglobulin test, was associated with a higher rate of reactions triggered by cold ambient air (P = 0.009) or immersion in cold water (P = 0.041), and aggravated by increased summer humidity (P = 0.007). Additionally, patients with a positive cold agglutinin test had a higher frequency of angioedema triggered by ingestion of cold foods or drinks (P = 0.043), and lower disease control based on Urticaria Control Test (P = 0.023). Cold agglutinin levels correlated with erythrocyte counts (r = −0.372, P = 0.028) and monocyte counts (r = −0.425, P = 0.011). Cryoglobulin concentrations correlated with basal serum tryptase levels (r = 0.733, P = 0.025) and cold urticaria duration (r = 0.683, P = 0.042). Results of our study suggest that cold agglutinins and cryoglobulins, in a subpopulation of cold urticaria patients, are linked to the course and possibly the pathogenesis of their disease.
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Affiliation(s)
- Mojca Bizjak
- Urticaria Center of Reference and Excellence (UCARE), University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Mitja Košnik
- Urticaria Center of Reference and Excellence (UCARE), University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Dorothea Terhorst-Molawi
- Urticaria Center of Reference and Excellence (UCARE), Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dejan Dinevski
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Marcus Maurer
- Urticaria Center of Reference and Excellence (UCARE), University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
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Gao Y, Chen D, Li Y, Chen H, Ran X. Extremity Gangrene Caused by HBV-Related Cryoglobulinemia Vasculitis in a Patient with Diabetes - A Case Report. J Inflamm Res 2021; 14:1661-1666. [PMID: 33953593 PMCID: PMC8092113 DOI: 10.2147/jir.s308687] [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: 03/02/2021] [Accepted: 04/14/2021] [Indexed: 02/05/2023] Open
Abstract
We presented a case of hepatitis B virus (HBV)-related type III cryoglobulinemia vasculitis (CryoVas) characterized by extremity gangrene in a patient with diabetes. The 60-year-old female had a 10-year history of poorly controlled type 2 diabetes mellitus. She complained of sudden onset pain and swelling of toes which quickly progressed to gangrene, with fingers becoming pain and dark violet. The patient was initially misdiagnosed as diabetic foot (DF). Although DF is one of the common chronic complications of diabetes, it rarely involves the hand. What is more, the ischemic manifestations of the extremity were not consistent with the results of the vascular examination and immune system changes. The patient had Raynaud's phenomenon, arthralgia, and extremity gangrene. Test results showed cryoglobulinemia multiple positive, polyclonal immunoglobulin with rheumatoid factor negative, lower complement 3, leukocytoclastic vasculitis, and HBV infection. HBV-related type III CryoVas was finally diagnosed, and a conservative therapy strategy was given. Six months after treatment with cyclophosphamide, corticosteroid, nucleoside/nucleotide analog therapy, local debridement, and dressing change, she recovered and kept no recurrence by following up for 30 months. To our knowledge, this is the first report of extremity gangrene caused by HBV-related CryoVas in a diabetic patient.
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Affiliation(s)
- Yunyi Gao
- Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Dawei Chen
- Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Yan Li
- Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Huijiao Chen
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Xingwu Ran
- Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
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Maltseva N, Borzova E, Fomina D, Bizjak M, Terhorst‐Molawi D, Košnik M, Kulthanan K, Meshkova R, Thomsen SF, Maurer M. Cold urticaria - What we know and what we do not know. Allergy 2021; 76:1077-1094. [PMID: 33249577 DOI: 10.1111/all.14674] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 11/13/2020] [Accepted: 11/18/2020] [Indexed: 12/16/2022]
Abstract
Cold urticaria (ColdU) is a common form of chronic inducible urticaria characterized by the development of wheals, angioedema or both in response to cold exposure. Recent research and guideline updates have advanced our understanding and management of ColdU. Today, its pathophysiology is thought to involve the cold-induced formation of autoallergens and IgE to these autoallergens, which provoke a release of proinflammatory mediators from skin mast cells. The classification of ColdU includes typical and atypical subtypes. We know that cold-induced wheals usually develop on rewarming and resolve within an hour and that anaphylaxis can occur. The diagnosis relies on the patient's history and cold stimulation testing. Additional diagnostic work-up, including a search for underlying infections, should only be done if indicated by the patient's history. The management of ColdU includes cold avoidance, the regular use of nonsedating antihistamines and the off-label use of omalizumab. However, many questions regarding ColdU remain unanswered. Here, we review what is known about ColdU, and we present important unanswered questions on the epidemiology, underlying pathomechanisms, clinical heterogeneity and treatment outcomes. Our aim is to guide future efforts that will close these knowledge gaps and advance the management of ColdU.
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Affiliation(s)
- Natalya Maltseva
- Center of Allergy and Immunology Clinical State Hospital 52 Moscow Ministry of Healthcare Moscow Russian Federation
| | - Elena Borzova
- Department of Dermatology and Venereology I.M. Sechenov First Moscow State Medical University Moscow Russian Federation
| | - Daria Fomina
- Center of Allergy and Immunology Clinical State Hospital 52 Moscow Ministry of Healthcare Moscow Russian Federation
- Department of Clinical Immunology and Allergology I.M.Sechenov First Moscow State Medical University Moscow Russian Federation
| | - Mojca Bizjak
- University Clinic of Respiratory and Allergic Diseases Golnik Golnik Slovenia
| | - Dorothea Terhorst‐Molawi
- Dermatological Allergology Allergie‐Centrum‐Charité Department of Dermatology and Allergy Charité – Universitätsmedizin Berlin Berlin Germany
| | - Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases Golnik Golnik Slovenia
| | - Kanokvalai Kulthanan
- Department of Dermatology Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand
| | - Raisa Meshkova
- Smolensk State Medical University Smolensk Russian Federation
| | - Simon Francis Thomsen
- Department of Dermatology Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
| | - Marcus Maurer
- Dermatological Allergology Allergie‐Centrum‐Charité Department of Dermatology and Allergy Charité – Universitätsmedizin Berlin Berlin Germany
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38
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Santiago MB, Paz A. Acute Peripheral and/or Cutaneous Ischemic Syndrome: What Rheumatologists Should Know. J Clin Rheumatol 2021; 27:73-79. [PMID: 33315786 DOI: 10.1097/rhu.0000000000001609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT In daily practice, the frequent appearance of limb and/or skin necrosis, which we term "acute peripheral and/or cutaneous ischemic syndrome" (APCIS), can be a manifestation of numerous underlying diseases, or it can sometimes be a clinical phenomenon whose etiology is undefined even after a wide investigation. The mechanisms for the development of APCIS include vessel wall abnormalities (atherosclerosis, vasculitis, and calciphylaxis), embolic processes (infectious endocarditis, atrial myxoma, and cholesterol emboli), local thrombotic injuries (genetic or acquired thrombophilias and heparin- and warfarin-induced ischemia), dysproteinemias (cryoglobulinemia and cryofibrinogenemia), or venous limb gangrene. Here, we report 5 illustrative cases of APCIS with different pathogenetic mechanisms, thereby highlighting some clinical conditions that cause APCIS that may be of special interest for rheumatologists, such as antiphospholipid syndrome, primary and secondary vasculitis, and cryoproteinemias. Furthermore, we describe a large spectrum of other causes of APCIS beyond the scope of rheumatology. Because there are no validated guidelines for APCIS, we tentatively propose an initial diagnostic workup and a therapeutic approach based on full-dose anticoagulation and immunosuppressive therapy.
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Affiliation(s)
| | - Adriane Paz
- From the Hospital Universitário Professor Edgard Santos
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39
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Bai W, Zhang L, Zhao J, Zhang S, Zhou J, Leng X, Liu Z, Ye W, Han B, Tian X, Li M, Zhao Y, Zeng X. Renal Involvement and HBV Infection Are Common in Chinese Patients With Cryoglobulinemia. Front Immunol 2021; 12:580271. [PMID: 33717064 PMCID: PMC7947000 DOI: 10.3389/fimmu.2021.580271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 02/03/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives: This study aimed to describe the main characteristics of Chinese patients with cryoglobulinemia, especially the characteristics of patients with different causes of cryoglobulinemia. Methods: Eighty inpatients diagnosed with cryoglobulinemia from different wards in Peking Union Medical College Hospital were included in this study. Demographic, clinical, biological, and renal pathological data were collected. We analyzed the characteristics of 61 patients with different causes of cryoglobulinemia. Results: Most patients (36/80, 45%) were diagnosed between 40 and 60 years of age. The male: female ratio was 1:1.5. Mixed (II + III) cryoglobulinemia accounted for the majority (43.8%) of cases. Renal involvement (87.5%), cutaneous involvement (57.5%), and fever (27.5%) were the most common clinical manifestations, while other manifestations included serositis and pulmonary and gastrointestinal involvement. The most common renal histopathological pattern was membranoproliferative glomerulonephritis (25/42, 59.5%). The secondary causes of cryoglobulinemia included infectious diseases (26/61, 32.5%), such as hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, and connective tissue diseases (22/61, 27.5%), such as lupus and hematologic tumors (13/61, 16.3%). Patients with hematologic tumors were diagnosed at an older age (P = 0.044) and mostly had type I cryoglobulinemia (P < 0.001). No significant difference in clinical or biological manifestations was found among patients with different causes of cryoglobulinemia. Conclusions: This is the largest cohort of Chinese patients with cryoglobulinemia. We found that renal involvement and HBV infection might be more common in Chinese patients with cryoglobulinemia.
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Affiliation(s)
- Wei Bai
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science and Technology, Beijing, China
| | - Lixia Zhang
- Department of Rheumatology, Shunyi District Hospital, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science and Technology, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science and Technology, Beijing, China
| | - Jiaxin Zhou
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science and Technology, Beijing, China
| | - Xiaomei Leng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science and Technology, Beijing, China
| | - Zhengyin Liu
- Department of Infectious Disease, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Wenling Ye
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Bing Han
- Department of Haematology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science and Technology, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science and Technology, Beijing, China
| | - Yan Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science and Technology, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science and Technology, Beijing, China
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40
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Wang CR, Tsai HW. Human hepatitis viruses-associated cutaneous and systemic vasculitis. World J Gastroenterol 2021; 27:19-36. [PMID: 33505148 PMCID: PMC7789062 DOI: 10.3748/wjg.v27.i1.19] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/19/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
Human hepatitis viruses (HHVs) include hepatitis A virus, hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis delta virus, and hepatitis E virus and can cause liver inflammation in their common human host. Usually, HHV is rapidly cleared by the immune system, following acute HHV invasion. The morbidities associated with hepatitis A virus and hepatitis E virus infection occur shortly after their intrusion, in the acute stage. Nevertheless, the viral infectious process can persist for a long period of time, especially in HBV and HCV infection, leading to chronic hepatitis and further progressing to hepatic cirrhosis and liver cancer. HHV infection brings about complications in other organs, and both acute and chronic hepatitis have been associated with clinical presentations outside the liver. Vascular involvement with cutaneous and systemic vasculitis is a well-known extrahepatic presentation; moreover, there is growing evidence for a possible causal relationship between viral pathogens and vasculitis. Except for hepatitis delta virus, other HHVs have participated in the etiopathogenesis of cutaneous and systemic vasculitis via different mechanisms, including direct viral invasion of vascular endothelial cells, immune complex-mediated vessel wall damage, and autoimmune responses with stimulation of autoreactive B-cells and impaired regulatory T-cells. Cryoglobulinemic vasculitis and polyarteritis nodosa are recognized for their association with chronic HHV infection. Although therapeutic guidelines for HHV-associated vasculitis have not yet been established, antiviral therapy should be initiated in HBV and HCV-related systemic vasculitis in addition to the use of corticosteroids. Plasma exchange and/or combined cyclophosphamide and corticosteroid therapy can be considered in patients with severe life-threatening vasculitis manifestations.
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Affiliation(s)
- Chrong-Reen Wang
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan 70403, Taiwan
| | - Hung-Wen Tsai
- Department of Pathology, National Cheng Kung University Hospital, Tainan 70403, Taiwan
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41
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Vacchi C, Visentini M, Gragnani L, Fraticelli P, Tavoni A, Filippini D, Saccardo F, Lauletta G, Colantuono S, Atzeni F, Pioltelli P, Manfredi A, Casato M, Zignego AL, Monti G, Pietrogrande M, Galli M, Sebastiani M. Safety and effectiveness of biosimilar of Rituximab CT-P10 in the treatment of cryoglobulinemic vasculitis: the MARBLe study (Mixed cryoglobulinemiA Rituximab BiosimiLar). Intern Emerg Med 2021; 16:149-156. [PMID: 32524338 DOI: 10.1007/s11739-020-02386-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/27/2020] [Indexed: 01/29/2023]
Abstract
Rituximab (RTX) represents a milestone in the treatment of mixed cryoglobulinemic vasculitis (MCV). Despite usually well-tolerated, RTX may induce different types of adverse drug reactions, including exacerbation of vasculitis. Recently, RTX biosimilar CT-P10 has been approved in Europe for the treatment of rheumatoid arthritis, but no data are available about effectiveness and safety of CT-P10 in the treatment of MCV. In this multicenter open-label study, we analyzed the safety of CT-P10 in patients with MCV treated in first-line or after a shift by RTX originator. Fifty-one consecutive MCV patients (females/males 35/16, median age 68 years, median disease duration 42 months, 51% HCV positive) were included in the study between July and December 2018 and were treated with CT-P10 (group 1). Safety and effectiveness of CT-P10 were compared with a retrospective group (group 2) including 75 consecutive patients treated with RTX originator between July 2017 and July 2018. Thirty-six patients were treated with CT-P10 for the first time, while the other 15 switched from RTX originator. RTX was administrated with high or dosage schemes (375 mg/m2 four times a week apart/1000 mg twice one week apart or 250 mg/m2 twice one week apart). During a month period after the last infusion, 13/51 adverse events (AE) were observed in group 1 and 17/75 in group 2 (p not significant). Among them, 7/13 and 6/17 (in group 1 and 2, respectively) could be considered immune-mediated AE (p not significant). At univariate analysis patients with IM-AE were more frequently males (p = 0.04) and with a lower disease duration (p = 0.03), but both the parameters were not significant at logistic regression. About clinical response after 6 months by the end of the treatment, no differences were observed between patients treated with originator and CT-P10 regarding the response to the therapy. No differences were observed in safety and effectiveness between patients naïve at RTX or switching from originator. Despite the higher prevalence of immune-mediated AE among patients treated with CT-P10 than originator, we have observed no significant differences between the 2 groups. The use of a low-dosage regimen is more common in group 1 than in group 2, representing a possible bias of the study, possibly influencing the appearance of AE. Considering the cost/efficacy ratio of biosimilars, their use could be helpful to treat a large number of MCV patients with an effectiveness and safety comparable to originator. Multicenter studies including a large number of patients and the new RTX biosimilars could be useful to fully elucidate the possible risk of immune-mediated adverse events with biosimilar drugs. Considering the cost/efficacy ratio of CT-P10, its use could help to treat a large number of MCV patients with an effectiveness and safety comparable to originator.
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Affiliation(s)
- Caterina Vacchi
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Marcella Visentini
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Laura Gragnani
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paolo Fraticelli
- Department of Internal Medicine, Azienda Ospedaliero Universitaria Ospedali Riuniti Di Ancona, Ancona, Italy
| | - Antonio Tavoni
- Clinical Immunology Unit, University Hospital of Pisa, Pisa, Italy
| | - Davide Filippini
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Gianfranco Lauletta
- Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Stefania Colantuono
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Fabiola Atzeni
- Rheumatology Unit, University of Messina, Messina, Italy
| | - Pietro Pioltelli
- Hematology Unit, AO San Gerardo, Università Di Milano-Bicocca, Monza, Italy
| | - Andreina Manfredi
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Milvia Casato
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Anna Linda Zignego
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giuseppe Monti
- Presidio Ospedaliero Di Saronno, ASST Della Valle Olona, Saronno, Italy
| | | | - Massimo Galli
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Marco Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy.
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Treppo E, Quartuccio L, Ragab G, DE Vita S. Rheumatologic manifestations of Hepatitis C Virus. Minerva Med 2020; 112:201-214. [PMID: 33263372 DOI: 10.23736/s0026-4806.20.07158-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Hepatitis C Virus (HCV) is a well-known worldwide infection, responsible for hepatic and extrahepatic complications. Among extrahepatic manifestation, the rheumatologic are the most common ones. With the arrival of Direct Antiviral Agents (DAA), the treatment and the clinical perspective have rapidly changed, permitting to achieve a sustained virological response (SVR) and preventing complications of chronic infection. EVIDENCE ACQUISITION We performed on PubMed a literature search for the articles published by using the search terms "HCV infection," "HCV syndrome," "HCV-related rheumatologic disorders," "cryoglobulinemia," "cryoglobulinemic vasculitis" and "mixed cryoglobulinemia." EVIDENCE SYNTHESIS Mixed cryoglobulinemia (MC) is the prototype of HCV-associated rheumatologic disorder. HCV-related MC is typically considered by physicians as a human model disease to linking infection with autoimmune diseases. Chronic HCV infection can lead to a multistep process from a simple serological alteration (presence of circulating serum cryoglobulins) to frank systemic vasculitis (cryoglobulinemic vasculitis [CV]) and ultimately to overt malignant B lymphoproliferation (such as non-Hodgkin lymphoma [NHL]). Antiviral therapy is indicated to eradicate the HCV infection and to prevent the complications of chronic infection. Immunosuppressive therapy is reserved in case of organ threatening manifestations of CV. In this review, we discuss the main clinical presentation, diagnostic approach and treatment of rheumatologic manifestations of HCV infection. CONCLUSIONS Chronic HCV infection is responsible for complex clinical condition, ranging from hepatic to extra-hepatic disorders. Cryoglobulins are the result of this prolonged immune system stimulation, caused by tropism of HCV for B-lymphocyte.
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Affiliation(s)
- Elena Treppo
- Department of Medicine, Rheumatology Clinic, University of Udine, ASUFC, Udine, Italy
| | - Luca Quartuccio
- Department of Medicine, Rheumatology Clinic, University of Udine, ASUFC, Udine, Italy -
| | - Gaafar Ragab
- Unit of Rheumatology and Clinical Immunology, Department of Internal Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Salvatore DE Vita
- Department of Medicine, Rheumatology Clinic, University of Udine, ASUFC, Udine, Italy
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43
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Pulmonary Imaging Findings of Vasculitis. CURRENT PULMONOLOGY REPORTS 2020. [DOI: 10.1007/s13665-020-00263-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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44
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Kleefeld F, Arendt G, Neuen-Jacob E, Maschke M, Husstedt I, Obermann M, Schmidt H, Hahn K. [Neurological complications of hepatitis C infections]. DER NERVENARZT 2020; 92:144-149. [PMID: 33001263 PMCID: PMC7873080 DOI: 10.1007/s00115-020-00999-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/03/2020] [Indexed: 12/26/2022]
Abstract
Die chronische Hepatitis-C-Virus(HCV)-Infektion ist eine hochprävalente Systemerkrankung, die verschiedene neurologische Komplikationen verursachen kann. Es lassen sich HCV-assoziierte Symptome im zentralen und peripheren Nervensystem sowie der Muskulatur unterscheiden. Wichtige Pathomechanismen sind die HCV-assoziierte Autoimmunität (z. B. gemischte Kryoglobulinämie mit Polyneuropathie) und direkte Neurotoxizität (z. B. bei HCV-assoziierten kognitiven Defiziten). Die häufigsten neurologischen Komplikationen sind distal-symmetrische Polyneuropathien, Small-fiber-Neuropathien und kognitive Defizite. Die HCV-Infektion stellt außerdem einen Risikofaktor für ischämische und hämorrhagische Schlaganfälle sowie den Morbus Parkinson dar. Die frühe Identifikation und antivirale Behandlung HCV-positiver Patienten steht im Zentrum der Behandlung. Durch neue antivirale Therapien können >90 % der Patienten dauerhaft von der HCV-Infektion geheilt werden.
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Affiliation(s)
- Felix Kleefeld
- Klinik für Neurologie, Universitätsmedizin Charité, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Gabriele Arendt
- Neurologie, Neuro-Centrum Düsseldorf, Hohenzollernstr. 5, 40211, Düsseldorf, Deutschland
| | - Eva Neuen-Jacob
- Institut für Neuropathologie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - Matthias Maschke
- Klinik für Neurologie, Krankenhaus der Barmherzigen Brüder, Nordallee 1, 54292, Trier, Deutschland
| | - Ingo Husstedt
- Praxis an der Klinik Maria Frieden, Am Krankenhaus 1, 48291, Telgte/Münster, Deutschland
| | - Mark Obermann
- Klinik für Neurologie, Asklepios Kliniken Schildautal, Karl-Herold-Str. 1, 38723, Seesen, Deutschland
| | - Holger Schmidt
- Klinik für Neurologie, Elbe-Kliniken Stade, Bremervörder Str. 111, 21682, Stade, Deutschland
| | - Katrin Hahn
- Klinik für Neurologie, Universitätsmedizin Charité, Charitéplatz 1, 10117, Berlin, Deutschland.
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Abstract
Given the visibility of cutaneous findings, skin manifestations are often a presenting symptom of underlying systemic disease, including chronic liver disease. Many cutaneous signs and symptoms that correlate with chronic liver disease are common physical examination findings in patients with no history of liver disease. It is nonetheless important to be aware that these cutaneous findings may be an indication of underlying liver disease and often occur in the setting of such hepatic dysfunction. This article covers general cutaneous signs that may correlate with various liver diseases and describes specific cutaneous signs as they relate to more specific liver diseases.
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Affiliation(s)
- Ashaki D Patel
- Department of Dermatology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
| | - Kimberly Katz
- Department of Dermatology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Kenneth B Gordon
- Department of Dermatology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
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Ralli M, Campo F, Angeletti D, Minni A, Artico M, Greco A, Polimeni A, de Vincentiis M. Pathophysiology and therapy of systemic vasculitides. EXCLI JOURNAL 2020; 19:817-854. [PMID: 32665772 PMCID: PMC7355154 DOI: 10.17179/excli2020-1512] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/15/2020] [Indexed: 12/14/2022]
Abstract
Systemic vasculitides represent uncommon conditions characterized by the inflammation of blood vessels that can lead to different complex disorders limited to one organ or potentially involving multiple organs and systems. Systemic vasculitides are classified according to the diameter of the vessel that they mainly affect (small, medium, large, or variable). The pathogenetic mechanisms of systemic vasculitides are still partly unknown, as well as their genetic basis. For most of the primary systemic vasculitides, a single gold standard test is not available, and diagnosis is often made after having ruled out other mimicking conditions. Current research has focused on new management protocol and therapeutic strategies aimed at improving long-term patient outcomes and avoiding progression to multiorgan failure with irreversible damage. In this narrative review, authors describe different forms of systemic vasculitides through a review of the literature, with the aim of highlighting the current knowledge and recent findings on etiopathogenesis, diagnosis and therapy.
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Affiliation(s)
- Massimo Ralli
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Flaminia Campo
- Department of Sense Organs, Sapienza University of Rome, Italy
| | | | - Antonio Minni
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Marco Artico
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Antonella Polimeni
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy
| | - Marco de Vincentiis
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy
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